NURSING LEADERSHIP AND MANAGEMENT

          Objectives:

At the end of this presentation, the participants should be able to:

Define leadership and management in nursing

Outline leadership and management theories, types and principles in nursing

Explain the importance of good management in a health service organization

Describe the managerial levels, roles and skills in nursing

Discus the common attributes of nurse leaders and managers





INTRODUCTION


Leadership generates a variety of thoughts and reflections to people. These may include power authority, influence, fellowship, dynamic personality, charisma, goals, innovation, cleverness, warmth and kindness. Leadership can be defined as a multifaceted process of identifying a goal or target, motivating other people to act, and providing support and motivation to achieve mutually negotiated goals (porter-O’ Grady, 2003). In the daily life of a senior nurse, this could refer to coordinating the day/night shift and the team of nurses and support staff on duty under the direction of that nurse. The successful operation of the shift, staff morale and managing difficult or challenging situations depends largely on the senior nurse’s leadership skills. It is important to appreciate that leadership role are different from management function.

Leadership is an attempt to influence groups or individuals without the coercive form of power. At its core meaning, leadership is about relationships with other people. It is important to successful organizational outcomes. Leadership involves much knowledge and disciplined practice. When nurses graduate they are not ready to assume a leadership role. They require opportunities in practice for self-discovery, to understand their strengths and for skill building.This paper provides an insight to the issues of nursing leadership, addressing definitions and theories underpinning leadership and factors that enhance nursing leadership and management.

LEDEARSHIP

Over the years, many definitions of leadership have existed in different dimensions, including:

 “The process by which an agent induces a subordinate to behave in a desired manner.” (bennis 2001)

Stogdill (2009) defined leadership as “the process of influencing the activities of an organized group in its efforts toward goal setting and goal achievement.” 

Leadership is the ability to influence people toward attainment of goals (Daft, 2000)

‘Leadership can also be defined as “influence”, that is, the art or process of influencing people so that they will strive willingly and enthusiastically toward the achievement of group goals’ (Weihrich and Koontz, 2005).

Sullivan and Garland (2010 leadership) describes it as the use of interpersonal skills to influence others to accomplish a specific goal’.

According to Wikipedia, leadership is a process of social influence in which one person can enlist the aid and support of others in the accomplishment of a common task.

The importance of effective leadership in health care has been emphasized by a number of authors (Sutherland and Dodd, 2008), and nursing leadership is pivoted to this, as nurses represent the largest discipline in health care. Changes in nursing leadership and management have been enlisted in creating safe environments for patients and staff—identified by the Institutes of Medicine (IOM) in its work on medical errors and patient safety.

QUALITIES OF A GOOD LEADER:

Some important qualities of a leader include:

Honest/Trustworthy/Integrity,               Intelligent/Educated/Experienced

Just/impartial/Fair,                                 Intelligent/Educated/Experienced 

Just/impartial/Fair                                  Respectful/Respects the people

Serve/Help the community,                   Loving/compassionate/kind

Strong moral values/Ethical person,      Good person/Responsible

Courageous/Tenacious,                          Humble/Sincere

Good communication skill,                     Patriot/Loves country 1

Hard working/ethical,                              Good listener/Accessible

Dedicated/Committed                             Dedicated /Committed,                            Goal oriented/Efficient

TYPES OF LEADERSHIP STYLE

 In general, one leadership style depends on personality, the type one feels comfortable with, the abilities of team members and the situation at hand. As a nurse you are an example to others-either positive or negative. It may be necessary for you to adopt characteristics from a verity of leadership styles based on the situation at hand. Regardless of the leadership activities needed, it is important to act with integrity to set realistic goals, to communicate clearly and often, to encourage others, to recognize the success of your team members, and to inspire them to provide the best of care. Ultimately your actions will be reflected by your staff in the care they give to your resident each day regardless of which style you practice. Leadership styles include:

SERVANT LEADERSHIP:

Servant Leadership is one that has grown in popularity in the last few years. In the 1970’s, Robert Greenleaf created this team to describe leaders who influence and motivate others by building relationships and developing the skills of individual team members. A Servant leader makes sure the needs of the individual team members are addressed. In this style, the entire team has input into decision making based on the organization’s values and ideals. Servant leaders create devoted followers in response to positive attention they give.

        Characteristic skills of a servant leader include


1.     Listening       2.Acceptance        3.Awareness

    4. Persuasion      5.Foresight          6.Commitment to the growth of others

    7. Building community within the organization

A transformational leadership:

A transformational leader is one who: “commits people to action, who converts followers into leaders, and who may convert leaders into agents of change.”Empowers staff to have a vision about the organization and entrust them to work toward goals that benefit the organization and themselves. Are futuristic and directs where energies are to be focused. Makes sure workers know their expectations. Decisions are based on fairness, equity, and honesty. This leader knows one’s self, ones skills and uses them effectively.

Characteristics of a transformational leader


Charismatic,       Engaging,              Inspirational,         Stable,

Optimistic,         Encouraging          Honest                    Motivational

Respectful            Positive                  Team oriented           Effective communicator

Empowering       Reliable                 Trustworthy            Emphatic

Mentor               Visionary

Democratic Leader:

Democratic Leader encourages open communication and staff participation in decisions. Workers are given responsibility/authority, accountability, and feedback expected regarding their performance. Relationships are important to this leader who places a focus on quality improvement of systems and process, rather than on mistakes of individual team members.

 Autocratic leadership style:

The authoritarian leadership style is demonstrated when a leader makes all decisions without considering input from staff. Negative reinforcement and punishment are often used to enforce rules. Because knowledge is seen as power, critical information may be withdrawn from the team. Mistakes are not tolerated and blame is placed on individuals rather than on faulty processes. There is little time for discussion. It is useful when enforcing policies and procedures that protect staff health and safety, but it does not promote trust, communication, or teamwork when used from day –to- day operations. Authoritarian leaders are often micro managers.

Laissez –faire Leadership:

Laissez –faire Leadership - is a style where the leader provides little or no direction or supervision, and prefers to take a hands-off approach. Decisions are not made, changes rarely occur, and quality improvement is typically reactive, not proactive. It is most often used by new, inexperienced leaders or those at the end of their career who choose not to address issues since things will soon be changed by their replacement leader.

Management by Walking Around Leadership Style (MBWA):

In a long-term care facility, nurse leaders are constantly on the move. As a result, many nurse leaders naturally adopt a leadership style known as Management by Walking Around (MBWA) or Leading by Walking Around (LBWA.) In addition to checking on clinical issues and keeping the environment looking homelike, MBWA prefers the opportunity to; observe team members, show interested in them and their work, evaluate the quality of care being delivered. Benefits include finding out what is going on through listening, teaching values by example, and facilitating others to achieve positive outcomes. By practicing MBWA more fully, you will motivate your staff to achieve desired goals.

Guidelines for the MBWA leadership style include:  Regularly monitoring and supervision, as often as you can, by yourself, don’t circumvent subordinate managers, ask questions, Watch and listen, bring good news, when you catch them in the act of doing something right, applaud them.


NURSES LEADERSHIP ROLE: Nursing process (problem-solving technique) :

Leaders make things happen! As a leader, the nurse, first priority is to get the Job done. In order to do this, nurse should make assessment and analysis of data/information, diagnosis/identify the problem, set objectives, plan for the attainment of goals, clarify them with the manager, implement and evaluate.

On assessment and analysis: gather information about the situation, identify the problem; separate the cues/symptoms identify people and groups involved identify cultural and environmental factors, encourage input from involved parties.

During analysis and diagnosis, analyze results of information gathered identify, clarify, and prioritize the actual problem (s) determine if intervention is appropriate.

On planning, list everything you have to do both short & long-term goals. Set priorities. Decide which t asks are the most important in achieving your objectives. Decide how much time you will need to complete each task. Check to see that resources needed to complete the task are available. Use wall calendars, desk calendars daily to do lists and other aids to develop a plan for getting jobs done.

On implementation, communicate plans to everyone involve, be sure plans, goals, and objectives are clearly identified, maintain open, two-way communication with staff, support and encourage compliance among all staff. Build a team committed to achieving those objectives. Set clear standards. Let your team know exactly what you expect in terms of quality and quality of work, time keeping, and following safety rules. Strive to maintain high but realistic standards. Explain the "Why" and “What". It is important for team members to understand why a task is necessary and why it must be done.

At last evaluationpossible outcome: identify evaluation criteria in the planning; identify who is responsible for evaluation, what will be measured, and when it will take place. Ask for team member's ideas and opinions. Team members who are involved in the decision making process are more likely to feel they have a stake in achieving goals. Be understanding. Keep in mind that everyone makes mistakes occasionally. Criticize constructive and tactful

MANAGEMENT

Management is as old as mankind and existed since man has been organized in to communities. Managers influence all phases of our modern organizations. Our society simply could not exist as we know it today or improve its present status without a steady stream of managers to guide its organizations. Peter Drucker (2000) makes this same point in stating that effective management is quickly becoming the main resource of developed countries and the most needed resource of developing ones. Essentially, the role of managers is to guide organizations toward goal accomplishment. All organizations exist for some purpose or objective, and mangers have the responsibility for combining and using organizational resources to ensure that the organizations achieve their purposes. Management moves organizations toward these purposes or goals by assigning activities that organization member perform. If these activities are designed effectively, the production of each individual worker represents a contribution to the attainment of organizational goals. Managers strive to encourage individual activity that will lead to reaching organizational goals and to discourage individual activity that hinders organizational goal accomplishment. Management must keep organizational goals clearly in mind at all times.

MANAGEMENT AND NURSING SERVICE ADMINISTRATION

Definition of management

Different authorities define management differently but have strong unifying similarities in all the definitions. The term management can be used in several ways. For instance, it can simply refer to the process that managers follow to accomplish organizational goals. The term can be used, however, to refer to a body of knowledge. In this context, management is a cumulative body of information that furnishes insight on how to manage.

Management is the art of getting things done through people. It is the process of reaching organizational goals by working with and through people and other organizational resources. It is the process of planning, organizing, leading and controlling the work of organization members and of using all available organizational resources to reach stated organizational goals. Management is principally the task of planning, coordinating, motivating and controlling the efforts of others towards a specific objective.

Management according to John Mee (2005) may be defined as the act of securing maximum result with a minimum of effort so as to secure maximum prosperity and happiness for both employer and employee and give the public the best possible service. Joseph Massie (2003) defined management as the process by which a cooperative group direct actions towards common goals. Stanley Vance 2009) also defined management as simply the process of decision making and control over the action of human being for the express purpose of attaining predetermined goal.

RELATIONSHIP BETWEEN LEADERSHIP AND MANAGEMENT

Leadership and management are intertwined concepts,though are different, but will be difficult to discuss without the other.

The terms “leader” and “manager” are too often used interchangeably, but most of us understand instinctively that they are not the same thing. Not every nurse manager is a good leader, and those who demonstrate strong nursing leadership are not necessarily managers. A nurse manager holds an assigned position within the hierarchy of an organization. She or he has decision-making powers and control over certain processes, and is expected to carry out specific duties.

A leader, on the other hand, may or may not have recognized authority within the organization. In many cases, the “power” held by a leader comes from the ability to influence others, through effective communication and interpersonal skills. Nurses can demonstrate leadership skills at any level of experience and in any stage of their careers. When a staff works productively within a unit and express enthusiasm for unit goals, the person is helping to direct the group in ways that makes it function cohesively – the person is sowing the seeds of leadership.

Both leaders and managers rely on critical thinking skills and the ability to envision a positive future. Ideally, nurse leaders have risen to the management or executive level because they’ve had the ambition to advance their careers and leave the bedside. The desire to improve for self-improvement and a higher level of excellence is an intrinsic trait for leaders.

The Differences between Nurse Leaders and Nurse Manager


While management and leadership have a great deal in common such as working with people and accomplishing the goals of the organization, they do differ in their primary function (kotter 2000). A leader often doesn’t have delegated authority. The “power” that the leader has acquired has come informally from others in group. Leaders focus on empowering others as well as motivating, inspiring, and influencing others. True leaders must be sincere and energetic. A leader may be a risk –taker, but not to the extent that others fell that they are reckless.

*       A manager is provided with this statue as a formal role which is given to him/her by someone else. He/she has an assigned position within the formal organization. A manager is expected to carry out specific duties and has definite responsibilities. Control over processes, decision making, and the work of others are included in the manager’s role. Good nursing managers are skilled at coordinating resources, both financial and personnel, following rules and meeting the goals and objectives of the organization. Managers typically focus on managing or maintaining equilibrium, whereas leaders are focused on change. Others include:

*       Leaders ask question, take risk and are challenged by change, in contrast, managers are typically less able to handle unstable or non-routine situations.

*       Leaders conquer the contest always going in around them while managers surrender to it.

*       Leaders access reality, identify critical factors and use analysis while managers accept the truth from others with few questions.

*       Leaders focus on effectiveness, managers’ focus on efficiency.

*       The leader originates; the manager imitates.

*       The leader asks what and why the manager asks how and when.

*       Leaders innovate and initiate; managers copy and keep the status quo.

*       The leader develops; the managers maintains.

*       The leader focuses on people; the manager focuses on system and structure.

*       The leader inspires trust; the manager relies on control.

*       The leader is his or her own person the manager is a classic good soldier.



QUALITIES OF A MANAGER

Vision/Mission andWisdom: should have ability to see and think about the future with imagination of an important task/assignment ahead. With wisdom, she is focused, not sitting to wait for events to occur before thinking of how to handle challenges. Wisdom is the ability to apply knowledge and experience to any given situation. It gives insight and the ability to recognize a problem before it becomes an emergency.

Hard working:  Elevation of a nurse practitioner to a ward manger often emanate from hard working, because success comes from hard-work. A hard worker does not believe in short cuts. She strives to maintain the highest standards to achieve excellence in nursing care of her patients.

Discipline:A ward manager must be disciplined because success is not possible without discipline. According to Houston and Marquis (2011), self discipline is the willingness to perform the acts that are beneficial to us even though we do not want to perform them because they may be unpleasant. She cannot be a truant, yet expects the subordinate to be angel.

Good listening with good communication skill: A good ward manager should have good listening/communication skill.She should always give a listening ear to the subordinates and patients under his care. Effective communication enhances understanding and cooperation. These make them feel important and respected.

Others include:  humility, tactful and diplomatic,courageous and confident.

MANAGEMENT FUNCTIONS OF A NURSE MANAGER

Success of management depends on learning and using the management functions; these functions include planning, organizing, staffing, directing, coordinating and controlling. Managers develop skills in the implementation of these functions as they gain experience in the role of managers. Nurse Managers also use the same functions as they fulfill their responsibilities in the organization.

Management Functions of a Nurse Manager

Success of management depends on learning and using the management functions. These functions include planning, organizing, staffing, directing, coordinating and controlling. These functions represent these activities expected of managers in all fields. Managers develop skill in the implementation of these functions as they gain experience in the role of managers.

PLANNING – Planning is a technical managerial function that enables organizations to deal with the present and anticipate the future. It is the first and fundamental function of management because all other management functions are dependent on it. Planning is deciding what is to be done, when it is to be done, how it is to be done and who is to do it. Planning is the process of determining exactly what the organization will do to accomplish its objectives. In more formal terms, planning has been defined as ‘the systematic development of action programmes aimed at reaching agreed objectives by the process of analyzing, evaluating and selecting among the opportunities which are foreseen. In the nursing process, planning includes writing objectives, setting priorities, and determining activities to meet the objectives.

STAFFING - Selecting the personnel to carry out these actions and placing them in positions appropriate to their knowledge and skills.

ORGANIZING  - Organizing may be defined as the arranging of component parts into functioning wholes. It involves mobilizing human and material resources so institutional objectives can be achieved. The purpose of organizing is to coordinate activities so that a goal can be achieved.  Planning, and organizing, may be viewed as being part of all processes, including the leadership process.  Planning and organizing may be said to answer the what, why, how, when, and where questions about specific activities. There are six steps in the organizing process:

1. Establish overall objectives.

2. Formulate supporting objectives, policies and plans.

3. Identify and classify activities necessary to accomplish the objectives

4. Group the activities in light of the human and material resources available and the best way of using them under the circumstances

5. Delegate to the head of each group and the authorities necessary to perform the activities.

Delegation -  is the process of assigning part or all of one person’s responsibility to another person or persons. Delegating is an effective management competency by which nurse managers get the work done through the employees.

The purpose of delegation is efficiency; no one person can do all the work that must be done; therefore, some work must be passed on, or delegated to others. However, it must be remembered that, even when an activity is delegated to someone else, the ultimate responsibility for that activity still belongs to the nurse-leader (i.e. the person who delegated the activity.

Nurse Managers need to be able to delegate some of their own duties, tasks, and responsibilities as a solution to overwork, which lead to stress, anger, and aggression. When a nurse manager, learn to accept the principle of delegation, they become more productive and come to enjoy relationships with the staff. The following list suggests ways for nurse managers to successfully delegate.

 How to Increase Your Expertise as a Delegator: Follow the five rights of delegation developed by National Council of State Boards of Nursing:

     Right task

     Right person

     Right communication

     Right supervision

     Right circumstances

Barriers to Delegating

v Preference for operating by oneself

v Demand that everyone “know all the details” “I can do it better myself” is fallacy.

v Lack of experience in the job or in delegating

v Insecurity

v Fear of being disliked

v Refusal to allow mistakes

v Lack of confidence in subordinates

v Perfectionism, leading to excessive control

v Lack of organizational skill in balancing workloads

v Failure to delegate authority commensurate with responsibility

v Uncertainty over tasks and inability to explain

v Disinclination to develop subordinates

v Failure to establish effective controls and to follow up

Barriers in the Delegation

ü Lack of experience

ü Lack of competence

ü Avoidance of responsibility

ü Over dependence on the boss

ü Overload of work

ü Immersion in trivia –pieces of information

6. Tie together (coordination)

Tie the groups together horizontally and vertically, through authority relationships, and information systems. The final step in the process of organizing is that of coordination. Group of group members must be placed horizontally and vertically into a framework of authority relationships and information systems in the organizational structure. The goal of organizing is the coordination of activities, and it is with this last step that the framework is fully established. It brings the whole process together. Even though all the five previous steps are satisfactorily completed, if the members’ activities are not tied in, the process can still fail. Members need to know to whom they can go for help and relief.

 DIRECTING - Motivating and leading personnel to carry out the actions needed to achieve the institution’s objectives.

Directing  gets work done through others. Directing includes five specific concepts; giving directions, supervising, leading, motivating, and communicating, as described below: Giving directions is the first activity and suggests that directions should be clear, concise and consistent and should confirm to the requirements of the situation. The manager should be aware of the tone of the directives. Different types of situations require different emphasis. For example, emergency situation calls for different variation of voice than does a routine request. Supervising is concerned with the training and discipline of the work force. It also includes follow up to ensure the prompt execution of orders. Leading is the ability to inspire and to influence others t the attainment of objectives. Motivating is the set of skills the manager uses to help the employee to identify his/her needs and finds ways within the organization to help satisfy them.

Communication: involves the what, how, by whom, and why of directives or effectively using the communication process. The manager should have good communication skill.

Effective Communication skill

Communication by definition is the transfer of information and understanding from one person to another. To be a leader, the staff must have a basic understanding of the communication process, which consists of a sender, a message and a receiver, all of which are influenced by an environment. Each of the components of the communication process is capable of enhancing or inhibiting the understanding of the message. Communication may be verbal and non-verbal.

Benefits of effective communication skill

}  It helps to establish clear expectations for employees and for clients as well.

}  Open channels of communication can lead to new ideas and innovation in a number of areas.

}  It lead to strong teamwork and the ability for employees at all levels of the organization to work together to achieve organizational goals.

}   It creates a sense of safety and protection to both the staff and the clients.

}  It improves levels of patient satisfaction and greater adherence to treatment options

COORDINATING - Coordinating is by definition the act of assembling and synchronizing people and activities so that they function harmoniously in the attainment of organizational objectives. Think about the situations in your own life when you have had to coordinate the multiple activities for an important event. An example in everyday life that demands coordination is a wedding.

CONTROLLING - Comparing results with predetermined standards of performance and taking corrective action when performance deviates from these standards. Is the regulation of activities in accordance with the plan. Controlling is a function of all managers at all levels. Its basic objective is to ensure that the task to be accomplished is appropriately executed. Control involves establishing standards of performance, determining the means to be used in measuring performance, evaluating performance, and providing feedback of performance data to the individual so behavior can be changed. Controlling is not manipulation, rigid, tight, and autocratic or oppression

TYPES OF MANAGERS:

Nurse Managers are people who are appointed to positions of authority, which enable them to perform their work effectively, who have responsibility for resource utilization and who are accountable for work results and can be proud of their organizations and what they do. Regardless of types/levels, managers have several common attributes e.g.  

Ø Formally appointed to positions of authority

Ø Charged with directing and enabling others to do their work effectively

Ø Responsible for utilizing resources

Ø Accountable to superiors for results

Traditionally classifications of managers are by level in the organizational hierarchy; common nomenclature include:

v Top level –such as board of directors, Presidents and vice presidents

v Middle level –such as directors of nursing, supervisory staffs and departmental heads.

v First line/front line/ or supervisory management –such as head nurses and staffs.

The primary differences between levels of managers are the degree of authority and the scope of responsibility and organizational activity at each level. For example, top-level managers such as nursing administrators have authority over and responsibility for the entire organization. Middle level managers such as department heads and heads of services have authority over and responsibility for a specific segment, in contrast to the organization as a whole and act as a liaison between top-level managers and first level managers. First line managers, who generally report to middle level managers have authority over and are responsible for overseeing specific work for a particular group of works.

Managerial Skills

Managers can also be differentiated by the extent to which they use certain skills which include:

v Conceptual skills - Senior managers use conceptual skills in their jobs than do middle level or first line managers. These include recognizing and evaluating multiple complex issues and understanding their relationships, engaging in planning and problem solving that profoundly affect the health service organization, and thinking globally about the organization and its environment.

v Human relations skills - All managers use human relation skills because they accomplish work through people. Human relations skills include motivation, leadership and communication skills. The degree to which each is used varies with the nature of the position, scope of responsibility, work activity, and number, types and skills of subordinates.

v Technical skills – First line managers’ use job related technical skills, or skills that involve specialized knowledge.

Managerial roles

All nurse managers engage in planning, organizing, staffing, directing, controlling, and decion making to some degree. In addition, they perform other activities related to accomplishing work and organizational objectives that do not readily fall within the functional classification. These roles are defined as the behavior or activities associated with a management position because of its authority and status. Mintzberg's classification identifies:

 interpersonal, informational and decisional roles

A.   Interpersonal role: The three aspect of interpersonal roles are:

Þ   Figurehead: all managers, but especially senior managers, are figureheads because they engage in ceremonial and symbolic activities such as greeting visitors and making speeches at organizational events.

Þ   Liaison: involves formal and informal internal and external contacts.

Þ   Influencer: includes activities inherent in the directing function, the purpose of which is to motivate and lead.

B.   Informational role: The three informational roles of a manager are

·        Monitor

·        Disseminator

·        Spokesperson

C.   Decisional Roles:The four decisional roles of a manager are

v Entrepreneur

v Disturbance handler e.g. conflict etc

v Resource allocator

v Negotiator

The Benefit of good Management in Health Service organizations

*       High lights priority areas

*       Adopts the service to the needs of a changing situation

*       Makes use of the most limited resources

*       Improves the standard and quality of services

*       Maintain high staff morale

LEADERSHIP AND MANAGEMENT THEORIES

 LEADERSHIP THEORIES

A. Trait Theories – If you have ever heard the statement that “leaders are born, not made”, then you have heard someone expressing the fundamental belief underlying a trait theory of leadership. Trait theories assume that a person must have a certain innate abilities, personality traits, or other characteristics in order to be a leader. If true, it would mean that some people are naturally better than others.

B. Great Man Theory – According to the “Great man” theory of leadership tremendous influence of some well known people has actually determined or changed the course of history. Some believe that these people possessed characteristics that made them great leaders. Such important historical figures, such as Caesar, Alexander the great, Hitler, and Gandhi.

Behavioral Theories

The behavioral theories, sometimes called the functional theories of leadership, still focus on the leader. The primary difference between the trait and behavioral theories is that the behavioral theories are concerned with what a leader does rather than who the leader is. They are still limited primarily to the leader element in a leadership situation, but they are far more action oriented and do consider the co-actors.

v Authoritarian-

v Democratic-

v Laissez-Faire styles

MANAGEMENT THEORIES

A. Situational Theories

1. Contingency Theory (Fred Fiedler) - In the contingency model, three situational variables are used to predict the favorability of a situation for the leader: the leader's interpersonal relations with group members, the leaders' legitimate power, and the task structure

2. Leader-member relations- the personal relationships between the leader and the members of the group. The better the relationships, the more favorable the situation.

3. Degree of task structure - how specifically the job can be defined so that everyone knows exactly what to do. (The more structured the task, the more favorable the situation).

4. Position Power - the leaders place within the organization and the amount of authority and power given to the leader. Position power may be strong or weak; it does not reflect the strength of the individual leader’s personality; rather it measures the leader’s status in the organization. The greater the position power, the more favorable the situation.

According to the contingency model, a nurse manager should modify situations based on group relations, personal power, and task structure to improve staff productivity. A nurse manager who uses the contingency model must have a thorough understanding of her/his relationship with staff members, her/his power and status within the organization, and the nature of the group task.

B. Path - Goal Theory (Robert House)

Robert House's Path Theory, introduced in 1971, is concerned with motivation and productivity. According to this theory, the motivational function of management is to help employees see the relationship between personal and organizational goals, clarify the "paths" to accomplishing these goals, remove obstacles to goal achievement, and reward employees for the work accomplished. Ouchi (1981)  approach to leadership, with a humanistic viewpoint and focuses on developing better ways to motivate people, with the view that this will lead to increased satisfaction and productivity.

 Motivation

Motivation is very important in health care institutions because, like in any other organization, people are required to function effectively if they are to provide adequate patient care.

a. Maslow’s theory(1943; 1954): is motivational theory which states that a lower level need is prerequisite, or controls behavior until it is satisfied, and then the next higher need energizes and directs behavior. The hierarchy, from the lowest to the highest level, is as follows: (a) physiological needs (e.g. hunger, thirst), (b) safety needs (i.e., bodily safety), (c) need for love and sense of belongings (e.g. friendship) affection, (love), and (d) need for self-esteem (e.g. recognition, appreciation, self respect) and (e) self actualization (e.g. developing one's whole potential). Maslow's need theory is frequently used in nursing to provide an explanation of human behavior.

THINGS MANAGERS MANAGE

Managers need to device and implement strategies, make plans and budgets, seek resources, implement, monitor and evaluate the plans, learn lessons and design new plans. Certain roles and responsibilities all general managers are involve with include:

*       Types and coverage of services to be delivered.

*       Resources (staffs, budgets, drugs and supplies, equipment, building, and other infrastructure and information) available for use.

*       People, including, patients, partners, suppliers and staff that are important for delivering functional quality services,

*       Performance Appraisal: performance appraisal is a systemic review of an individual employee's performance on the job, which is used to evaluate the effectiveness of his/her work. This provide information for management decisions regarding such matters as salary increments, promotions, transfers, as well as helps to assist employees in their personal development.

*       Organizational Structure:

Organizational structure refers to the lines of authority, communication, and delegation; can be formal or informal. Organizational process refers to the methods used to achieve organizational goals. An organization's formal structure is depicted in its organizational chart that provides a "blueprint," depicting formal relations, functions and activities.

The principal purpose for defining the organization diagram is to clarify chain of command, span of control, official communication channels, and linkage for all department personnel. It is customary to show formal organization structure in a diagrammatic form. Boxes containing various position titles are positioned vertically to highlight differences in status and responsibility. Position boxes are connected with lines to demonstrate the flow of communication and authority throughout the entire network.

Conclusion

The terms “leader” and “manager” are too often used interchangeably, people understand instinctively that they are intertwine, yet not the same. The importance of Nursing leadership and management can never be over emphasized as nurses represent the largest discipline in health care. Leaders cum managers are responsible for articulating a preferred future for our profession and its practitioners, whether they are in clinical, administrative, educational, resource, health policy or other roles. Therefore, those of us in the profession have to make a concerted effort to increase the visibility of nurses, enhance the image of the profession, work together in validating nurses’ contributions to providing effective and efficient patient care, develop partnerships, network with all members of the health care team, and promote increased access to nurses for all people in need of healthcare.


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