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Making Decisions and Solving Problems

CHAPTER 6 Making Decisions and Solving Problems Rose Aguilar Welch This chapter describes the key concepts related to problem solving and decision making. The primary steps of the problem-solving and decision-making processes, as well as analytical tools used for these processes, are explored. Moreover, strategies for individual or group problem solving and decision making are presented. Objectives •  Apply a decision-making format to list options to solve a problem, identify the pros and cons of each option, rank the options, and select the best option. •  Evaluate the effect of faulty information gathering on a decision-making experience. •  Analyze the decision-making style of a nurse leader/manager. •  Critique resources on the Internet that focus on critical thinking, problem solving, and decision making. Terms to Know autocratic creativity critical thinking decision making democratic optimizing decision participative problem solving satisficing decision The Challenge Vickie Lemmon RN, MSN Director of Clinical Strategies and Operations, WellPoint, Inc., Ventura, California Healthcare managers today are faced with numerous and complex issues that pertain to providing quality services for patients within a resource-scarce environment. Stress levels among staff can escalate when problems are not resolved, leading to a decrease in morale, productivity, and quality service. This was the situation I encountered in my previous job as administrator for California Children Services (CCS). When I began my tenure as the new CCS administrator, staff expressed frustration and dissatisfaction with staffing, workload, and team communications. This was evidenced by high staff turnover, lack of teamwork, customer complaints, unmet deadlines for referral and enrollment cycle times, and poor documentation. The team was in crisis, characterized by in-fighting, blaming, lack of respectful communication, and lack of commitment to program goals and objectives. I had not worked as a case manager in this program. It was hard for me to determine how to address the problems the staff presented to me. I wanted to be fair but thought that I did not have enough information to make immediate changes. My challenge was to lead this team to greater compliance with state-mandated performance measures. What do you think you would do if you were this nurse? Introduction Problem solving and decision making are essential skills for effective nursing practice. Carol Huston (2008) identified “expert decision-making skills” as one of the eight vital leadership competencies for 2020. These processes not only are involved in managing and delivering care but also are essential for engaging in planned change. Myriad technologic, social, political, and economic changes have dramatically affected health care and nursing. Increased patient acuity, shorter hospital stays, shortage of healthcare providers, increased technology, greater emphasis on quality and patient safety, and the continuing shift from inpatient to ambulatory and home health care are some of the changes that require nurses to make rational and valid decisions. Moreover, increased diversity in patient populations, employment settings, and types of healthcare providers demands efficient and effective decision making and problem solving. More emphasis is now placed on involving patients in decision making and problem solving and using multidisciplinary teams to achieve results. Nurses must possess the basic knowledge and skills required for effective problem solving and decision making. These competencies are especially important for nurses with leadership and management responsibilities. Definitions Problem solving and decision making are not synonymous terms. However, the processes for engaging in both processes are similar. Both skills require critical thinking, which is a high-level cognitive process, and both can be improved with practice. Decision making is a purposeful and goal-directed effort that uses a systematic process to choose among options. Not all decision making begins with a problem situation. Instead, the hallmark of decision making is the identification and selection of options or alternatives. Problem solving, which includes a decision-making step, is focused on trying to solve an immediate problem, which can be viewed as a gap between “what is” and “what should be.” Effective problem solving and decision making are predicated on an individual’s ability to think critically. Although critical thinking has been defined in numerous ways, Scriven and Paul (2007) refer to it as “ the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.” Effective critical thinkers are self-aware individuals who strive to improve their reasoning abilities by asking “why,” “what,” or “how.” A nurse who questions why a patient is restless is thinking critically. Compare the analytical abilities of a nurse who assumes a patient is restless because of anxiety related to an upcoming procedure with those of a nurse who asks if there could be another explanation and proceeds to investigate possible causes. It is important for nurse leaders and managers to assess staff members’ ability to think critically and enhance their knowledge and skills through staff-development programs, coaching, and role modeling. Establishing a positive and motivating work environment can enhance attitudes and dispositions to think critically. Creativity is essential for the generation of options or solutions. Creative individuals can conceptualize new and innovative approaches to a problem or issue by being more flexible and independent in their thinking. It takes just one person to plant a seed for new ideas to generate . The model depicted in Figure 6-1 demonstrates the relationship among related concepts such as professional judgment, decision making, problem solving, creativity, and critical thinking. Sound clinical judgment requires critical or reflective thinking. Critical thinking is the concept that interweaves and links the others. An individual, through the application of critical-thinking skills, engages in problem solving and decision making in an environment that can promote or inhibit these skills. It is the nurse leader’s and manager’s task to model these skills and promote them in others. FiGURE 6-1 Problem-solving and decision-making model. Decision Making This section presents an overview of concepts related to decision models, decision-making styles, factors affecting decision making, group decision making (advantages and challenges), and strategies and tools. The phases of the decision-making process include defining objectives, generating options, identifying advantages and disadvantages of each option, ranking the options, selecting the option most likely to achieve the predefined objectives, implementing the option, and evaluating the result. Box 6-1 contains a form that can be used to complete these steps. BOX 6-1    Decision-Making Format Objective: _____________________________________ Options Advantages Disadvantages Ranking                                 Add more rows as necessary. Rank priority of options, with “1” being most preferred. Select the best option. Implementation plan: ______________________________________________________________________________ Evaluation plan: __________________________________________________________________________________ A poor-quality decision is likely if the objectives are not clearly identified or if they are inconsistent with the values of the individual or organization. Lewis Carroll illustrates the essential step of defining the goal, purpose, or objectives in the following excerpt from Alice’s Adventures in Wonderland: One day Alice came to a fork in the road and saw a Cheshire Cat in a tree. “Which road do I take?” she asked. His response was a question: “Where do you want to go?” “I don’t know,” Alice answered. “Then,” said the cat, “it doesn’t matter.” Decision Models The decision model that a nurse uses depends on the circumstances. Is the situation routine and predictable or complex and uncertain? Is the goal of the decision to make a decision conservatively that is just good enough or one that is optimal? If the situation is fairly routine, nurse leaders and managers can use a normative or prescriptive approach. Agency policy, standard procedures, and analytical tools can be applied to situations that are structured and in which options are known. 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 different approach. In this case, a descriptive or behavioral approach is required. More information will need to be gathered to address the situation effectively. Creativity, experience, and group process are useful in dealing with the unknown. In the business world, Camillus described complex problems that are difficult to describe or resolve as “wicked” (as cited in Huston, 2008 ). This term is apt in describing the issues that nurse leaders face. In these situations, it is especially important for nurse leaders to seek expert opinion and involve key stakeholders. Another strategy is satisficing. In this approach, the decision maker selects the solution that minimally meets the objective or standard for a decision. It allows for quick decisions and may be the most appropriate when time is an issue. 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 using this approach, although it does take longer to arrive at a decision. For example, a nursing student approaching graduation is contemplating seeking employment in one of three acute care hospitals located within a 40-mile radius of home. The choices are a medium-size, not-for-profit community hospital; a large, corporate-owned hospital; and a county facility. A satisficing decision might result if the student nurse picked the hospital that offered a decent salary and benefit packet or the one closest to home. However, an optimizing decision is more likely to occur if the student nurse lists the pros and cons of each acute care hospital being considered such as salary, benefits, opportunities for advancement, staff development, and mentorship programs. Decision-Making Styles The decision-making style of a nurse manager is similar to the leadership style that the manager is likely to use. A manager who leans toward an autocratic style may choose to make decisions independent of the input or participation of others. This has been referred to as the “decide and announce” approach, an authoritative style. On the other hand, a manager who uses a democratic or participative approach to management involves the appropriate personnel in the decision-making process. It is imperative for managers to involve nursing personnel in making decisions that affect patient care. One mechanism for doing so is by seeking nursing representation on various committees or task forces. Participative management has been shown to increase work performance and productivity, decrease employee turnover, and enhance employee satisfaction. Any decision style can be used appropriately or inappropriately. Like the tenets of situational leadership theory, the situation and circumstances should dictate which decision-making style is most appropriate. A Code Blue is not the time for managers to democratically solicit volunteers for chest compressions! The autocratic method results in more rapid decision making and is appropriate in crisis situations or when groups are likely to accept this type of decision style. However, followers are generally more supportive of consultative and group approaches. Although these approaches take more time, they are more appropriate when conflict is likely to occur, when the problem is unstructured, or when the manager does not have the knowledge or skills to solve the problem. Exercise 6-1 Interview colleagues about their most preferred decision-making model and style. What barriers or obstacles to effective decision making have your colleagues encountered? What strategies are used to increase the effectiveness of the decisions made? Based on your interview, is the style effective? Why or why not? Factors Affecting Decision Making Numerous factors affect individuals and groups in the decision-making process. Tanner (2006) conducted an extensive review of the literature to develop a Clinical Judgment Model. Out of the research, she concluded that five principle factors influence decision making. (See the Literature Perspective below.) Literature Perspective Resource: Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45 (6), 204-211. Tanner engaged in an extensive review of 200 studies focusing on clinical judgment and clinical decision making to derive a model of clinical judgment that can be used as a framework for instruction. The first review summarized 120 articles and was published in 1998. The 2006 article reviewed an additional 71 studies published since 1998. Based on an analysis of the entire set of articles, Tanner proposed five conclusions which are listed below. The reader is referred to the article for detailed explanation of each of the five conclusions. The author considers clinical judgment as a “problem-solving activity.” She notes that the terms “clinical judgment,” “problem solving,” “decision making,” and “critical thinking” are often used interchangeably. For the purpose of aiding in the development of the model, Tanner defined clinical judgment as actions taken based on the assessment of the patient’s needs. Clinical reasoning is the process by which nurses make their judgments (e.g., the decision-making process of selecting the most appropriate option) ( Tanner, 2006 , p. 204): 1.  Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand. 2.  Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns. 3.  Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit. 4.  Nurses use a variety of reasoning patterns alone or in combination. 5.  Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. The Clinical Judgment Model developed through the review of the literature involves four steps that are similar to problem-solving and decision-making steps described in this chapter. The model starts with a phase called “Noticing.” In this phase, the nurse comes to expect certain responses resulting from knowledge gleaned from similar patient situations, experiences, and knowledge. External factors influence nurses in this phase such as the complexity of the environment and values and typical practices within the unit culture. The second phase of the model is “Interpreting,” during which the nurse understands the situation that requires a response. The nurse employs various reasoning patterns to make sense of the issue and to derive an appropriate action plan. The third phase is “Responding,” during which the nurse decides on the best option for handling the situation. This is followed by the fourth phase, “Reflecting,” during which the nurse assesses the patient’s responses to the actions taken. Tanner emphasized that “reflection-in-action” and “reflection-on-action” are major processes required in the model. Reflection-in-action is real-time reflection on the patient’s responses to nursing action with modifications to the plan based on the ongoing assessment. On the other hand, reflection-on-action is a review of the experience, which promotes learning for future similar experiences. Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. As Tanner (2006) so eloquently concludes, “If we, as nurse educators, help our students understand and develop as moral agents, advance their clinical knowledge through expert guidance and coaching, and become habitual in reflection-on-practice, they will have learned to think like a nurse” ( p. 210 ). Implications for Practice Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. For example, students and practicing nurses can be encouraged to maintain reflective journals to record observations and impressions from clinical experiences. In clinical post-conferences or staff development meetings, the nurse educator and manager can engage them in applying to their lived experiences the five conclusions Tanner proposed. The ultimate goal of analyzing their decisions and decision-making processes is to improve clinical judgment, problem-solving, decision-making, and critical-thinking skills. Internal and external factors can influence how the situation is perceived. Internal factors include variables such as the decision maker’s physical and emotional state, personal philosophy, biases, values, interests, experience, knowledge, attitudes, and risk-seeking or risk-avoiding behaviors. External factors include environmental conditions, time, and resources. Decision-making options are externally limited when time is short or when the environment is characterized by a “we’ve always done it this way” attitude. Values affect all aspects of decision making, from the statement of the problem/issue through the evaluation. Values, determined by one’s cultural, social, and philosophical background, provide the foundation for one’s ethical stance. The steps for engaging in ethical decision making are similar to the steps described earlier; however, alternatives or options identified in the decision-making process are evaluated with the use of ethical resources. Resources that can facilitate ethical decision making include institutional policy; principles such as autonomy, nonmaleficence, beneficence, veracity, paternalism, respect, justice, and fidelity; personal judgment; trusted co-workers; institutional ethics committees; and legal precedent. Certain personality factors, such as self-esteem and self-confidence, affect whether one is willing to take risks in solving problems or making decisions. Keynes (2008) asserts that individuals may be influenced based on social pressures. For example, are you inclined to make decisions to satisfy people to whom you are accountable or from whom you feel social pressure? Characteristics of an effective decision maker include courage, a willingness to take risks, self-awareness, energy, creativity, sensitivity, and flexibility. Ask yourself, “Do I prefer to let others make the decisions? Am I more comfortable in the role of ‘follower’ than leader? If so, why?” Exercise 6-2 Identify a current or past situation that involved resource allocation, end-of-life issues, conflict among healthcare providers or patient/family/significant others, or some other ethical dilemma. Describe how the internal and external factors previously described influenced the decision options, the option selected, and the outcome. Group Decision Making There are two primary criteria for effective decision making. 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 problem-solving and decision-making process. In reality, with the increased focus on quality and safety, decisions cannot be made alone. When individuals are allowed input into the process, they tend to function more productively and the quality of the decision is generally superior. Taking ownership of the process and outcome provides a smoother transition. Multidisciplinary teams should be used in the decision-making process, especially if the issue, options, or outcome involves other disciplines. Research findings suggest that groups are more likely to be effective if members are actively involved, the group is cohesive, communication is encouraged, and members demonstrate some understanding of the group process. In deciding to use the group process for decision making, it is important to consider group size and composition. If the group is too small, a limited number of options will be generated and fewer points of view expressed. Conversely, if the group is too large, it may lack structure, and consensus becomes more difficult. Homogeneous groups may be more compatible; however, heterogeneous groups may be more successful in problem solving. Research has demonstrated that the most productive groups are those that are moderately cohesive. In other words, divergent thinking is useful to create the best decision. For groups to be able to work effectively, the group facilitator or leader should carefully select members on the basis of their knowledge and skills in decision making and problem solving. Individuals who are aggressive, are authoritarian, or manifest self-oriented behaviors tend to decrease the effectiveness of groups. The nurse leader or manager should provide a nonthreatening and positive environment in which group members are encouraged to participate actively. Using tact and diplomacy, the facilitator can control aggressive individuals who tend to monopolize the discussion and can encourage more passive individuals to contribute by asking direct, open-ended questions. Providing positive feedback such as “You raised a good point,” protecting members and their suggestions from attack, and keeping the group focused on the task are strategies that create an environment conducive to problem solving. Advantages of Group Decision Making The advantages of group decision making are numerous. The adage “two heads are better than one” illustrates that when individuals with different knowledge, skills, and resources collaborate to solve a problem or make a decision, the likelihood of a quality outcome is increased. More ideas can be generated by groups than by individuals functioning alone. In addition, when followers are directly involved in this process, they are more apt to accept the decision, because they have an increased sense of ownership or commitment to the decision. Implementing solutions becomes easier when individuals have been actively involved in the decision-making process. Involvement can be enhanced by making information readily available to the appropriate personnel, requesting input, establishing committees and task forces with broad representation, and using group decision-making techniques. The group leader must establish with the participants what decision rule will be followed. Will the group strive to achieve consensus, or will the majority rule? In determining which decision rule to use, the group leader should consider the necessity for quality and acceptance of the decision. Achieving both a high-quality and an acceptable decision is possible, but it requires more involvement and approval from individuals affected by the decision. Groups will be more committed to an idea if it is derived by consensus rather than as an outcome of individual decision making or majority rule. Consensus requires that all participants agree to go along with the decision. Although achieving consensus requires considerable time, it results in both high-quality and high-acceptance decisions and reduces the risk of sabotage. Majority rule can be used to compromise when 100% agreement cannot be achieved. This method saves time, but the solution may only partially achieve the goals of quality and acceptance. In addition, majority rule carries certain risks. First, if the informal group leaders happen to fall in the minority opinion, they may not support the decision of the majority. Certain members may go so far as to build coalitions to gain support for their position and block the majority choice. After all, the majority may represent only 51% of the group. In addition, group members may support the position of the formal leader, although they do not agree with the decision, because they fear reprisal or they wish to obtain the leader’s approval. In general, as the importance of the decision increases, so does the percentage of group members required to approve it. To secure the support of the group, the leader should maintain open communication with those affected by the decision and be honest about the advantages and disadvantages of the decision. The leader should also demonstrate how the advantages outweigh the disadvantages, suggest ways the unwanted outcomes can be minimized, and be available to assist when necessary.

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Nursing Leadership and Management

Nov 11, 2011

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Nursing Leadership and Management. LET HIM THAT WOULD MOVE THE WORLD, FIRST MOVE HIMSESF. - Socrates. CONTENTS. Leadership and Management Defined and Distinguished Leadership and Management Theory Management Functions Roles of the Nurse Manager Creating a Caring Environment

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• accomplish work
• problem solving
• staff development
• learned leadership skills
• planning includes defining goals

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LET HIM THAT WOULD MOVE THE WORLD, FIRST MOVE HIMSESF. - Socrates

CONTENTS • Leadership and Management Defined and Distinguished • Leadership and Management Theory • Management Functions • Roles of the Nurse Manager • Creating a Caring Environment • Leadership and Management Skills and Behaviors

Leadership Defined and Distinguished • Leadership Defined • Management Defined • Leadership and Management concepts • Power and Authority • Formal and Informal Leadership

Leadership Defined Leadership combines: • intrinsic personality traits, • learned leadership skills, • characteristics of the situation. Leader - • guides people and groups to accomplish common goals, • influences the beliefs, opinions, or behaviors of a person, group, or groups of people.

Nurse leader is able to inspire others on the health care team to make patient education an important aspect of all care activities. Leadership qualities: unique personality characteristics, exceptional clinical expertise, relationships with others in the organization.

Management Defined Management - • coordinates people, time, and supplies to achieve desired outcomes, • involves problem-solving and decision-making processes. Managers responsibility: • maintain control of the day-to-day operations, • achieve established goals and objectives.

Nurse manager will have: an appointed management position within the organization with responsibilities to perform administrative tasks: • planning staffing requirements, • performing employee performance appraisals, • controlling use of supplies and time, • meeting budget and productivity goals.

Leadership and Management • are intertwined concepts, • are different, • difficult to discuss one without the other .

Leadership, management skills: -complementary; - can be learned and developed: through experience, improving skills in one area will enhance abilities in the other. A good manager also should be a good leader

Power and Authority Nurse manager has • authority - formal right to direct others granted by the organization, • power - ability to motivate people to get things done with or without the formal right granted by the organization, • ability to influence others to accomplish goals.

Formal and Informal Leadership Formal leadership practices by: • nurse manager, • supervisor, • charge nurse, • coordinator and gives the authority to act by the organization.

Informal Leadership is exercised by the person who • has no official or appointed authority to act, • is able to persuade, • is able to influence others in the work group, • strategies the nurse manager can use to work with informal leaders.

Leadership and Management Theory • Leadership Trait Theory • Interactional Leadership Theories • Transformational Leadership • Management Theory • Organizational Theory

Leadership, management, and organizational theories provide the building blocks on which to build effective nursing management practices and skills.

Contemporary theories of leadership depends on several variables, including (Marquis and Huston, 2000): • 1. Organizational culture. • 2. Values of the leader. • 3. Values of the followers. • 4. Influence of the leader/manager. • 5. Complexities of the situation. • 6. Work to be accomplished. • 7. Environment.

Transformational leaders • Identify and clearly communicate vision and direction. • Empower the work group to accomplish goals and achieve the vision. • Impart meaning and challenge to work. • Are admired and emulated. • Provide mentoring to individual staff members based on need.

Transactional leaders • Focus on day-to-day operations and are comfortable with the status quo (the existing state of affairs). • Reward staff for desired work ("I'll do x in exchange for you doing y"). • Monitor work performance and correct as needed; or • Wait until problems occur and then deal with the problem.

Management Theory • Behavioral theories explain aspects of management and leadership based on behaviors of managers/leaders and followers.Organizational Theory • provides a framework for understanding complex organizations, • helps to understand the management process.

Management Functions • Planning • Organizing • Staffing • Directing • Controlling

Planning includes defining goals and objectives, developing policies and procedures; determining resource allocation; and developing evaluation methods. • Organizing includes identifying the management structure to accomplish work, determining communication processes, and coordinating people, time and work. • Staffing includes those activities required to have qualified people accomplish work such as recruiting, hiring, training, scheduling and ongoing staff development.

Directing encourages employees to accomplish goals and objectives and involves communicating, delegating, motivating, and managing conflict. • Controlling analyzes results to evaluate accomplishments and includes evaluating employee performance, analyzing financial activities, and monitoring quality of care.

Roles of the Nurse Manager • Customer Service Provider • Team Builder • Resource Manager • Decision Maker and • Problem Solver • Change Agent

Customer Service Provider • Providing service or care to customers (patient or clients). • Nurse must keep customer service first and foremost as the motivator of all plans and activities. • Without customers, the organization will go out of business.

A team is a group of people organized to accomplish the necessary work of an organization. Team Builder

Teams have become important in the changing health care environment. • Teams bring together a range of people with different knowledge, skills, and experiences to meet customer.

Resource Manager • Resources include the personnel, time, and supplies needed to accomplish the goals of the organization. • Nurse manager has the responsibility - effectively manage resources in providing safe, effective patient care in an economic manner.

Three Types of Budgets 1. Personnel Allocates funds for salaries, overtime, benefits, staff development and training, and employee turnover costs 2. Operating budget Allocates funds for daily expenses such as utilities, repairs, maintenance, and patient care supplies 3. Capital budget Allocates funds for construction projects and/or long-life equipment such as cardiac monitors, defibrillators, and computer hardware; capital budget items are generally more expensive than operating supplies.

Decision Maker and Problem Solver • components of effective leadership and management in clinical patient care. • Problem solving is focused on solving an immediate problem and • decision maker includes a decision-making step.

Nursing process = problem-solving process includes : • assessment, • analysis and diagnosis, • planning, • implementation, • evaluation; • has proven to be effective to manage the complex decisions.

ASSESSMENT • Gather information about the situation • Identify the problem; separate the symptoms • Identify people and groups involved • Identify cultural and environmental factors • Encourage input from involved parties

ANALYSIS AND DIAGNOSIS • Analyze results of information gathered • Identify, clarify, and prioritize the actual problem (s) • Determine if intervention is appropriate

PLANNING • Identify as many solutions as possible • Elicit participation from people or groups affected • Review options and consider safety, efficiency, costs, quality, and legal issues • Consider positive and negative outcomes • Remain open-minded and flexible when considering options

IMPLEMENTING • Communicate plans to everyone affected • Be sure plans, goals, and objectives are clearly identified • Maintain open, two-way communication with staff • Support and encourage compliance among all staff

EVALUATION • Identify evaluation criteria in the planning • Identify who is responsible for evaluation, what will be measured, and when it will take place • Maintain open communication with all involved • Was the decision successful? • What might have made it better?

The nurse - change agent • is responsible for guiding people • through the change process and needs • to develop an understanding about the nature of change and effective change strategies.

1. Change should be implemented only for good reason. • 2. Change should always be planned and implemented gradually. • 3. Change should never be unexpected or abrupt. • 4. All people who may be affected by the change should be involved in planning for the change.

The most important responsibility for the nurse in any leadership or management • role is to create an environment of caring - caring for staff members as well as for patients and families.Staff members who believe that their manager sincerely cares about them and the work they do are able to pass that feeling of caring on to their patients and other customers.

Caring for the staff members can be demonstrated through (McNeese-Smith, 1997): • Offering sincere positive recognition for both individuals and teams. • Praising and giving thanks for a job well done. • Spending time with staff members to reinforce positive work behaviors.

Meeting the staff member's personal needs whenever possible, such as accommodating scheduling needs for family events and being flexible in times of illness. • Providing guidance and support for professional and personal growth. • Maintaining a positive, confident attitude and a pleasant work environment.

LEADERSHIP AND MANAGEMENT SKILLS AND BEHAVIORS Hersey and Blanchard (1988) have identified that effective leadership and management requiresskills in three major areas: • Technical skills—such as clinical expertise and nursing knowledge. • Human skills—the ability and judgment to work with people in an effective leadershiprole.

Conceptual skills—the ability to understand the complexities of the overall organization • and where one's own area of management fits into the overall organization.

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Use of Simulation in Teaching Nursing Leadership and Management Course

Nursing education is strategically positioned to prepare nursing students for management and leadership skills necessary for future professional nursing roles. This review appraised and synthesised the outcomes of using simulation in pre-licensure nursing management and leadership courses. This is an integrative review of original articles published between 2008 and 2018. In January 2019, PsychINFO, CINAHL, PubMed and SCOPUS were searched to identify relevant articles using the following terms: ‘management’, ‘leadership’, ‘simulation’, ‘nursing’, ‘education’ and ‘student’. A total of 10 articles were included in the review. Four essential themes were identified from the content analysis: acquisition of skills or understanding of delegation, enhanced teamwork or collaboration capacities, improved decision-making and problem-solving skills and increased communication skills. Incorporation of simulation in the nursing management and leadership courses has the potential to enhance nursing students’ skills regarding delegation, problem-solving capacities, decision-making and communication and teamwork.

Nursing education is vital in the formation of student nurses’ management and leadership competencies for future leadership roles. Several organisations, including academic institutions, healthcare agencies and accrediting entities, highlight the crucial need for student nurses to possess the leadership and management skills upon graduation. For example, the Institute of Medicine and the American Association of Colleges of Nursing suggest that all student nurses graduating from nursing school possess management and leadership competencies necessary in working and collaborating with multidisciplinary healthcare teams. 1 , 2 In particular, the American Organization of Nurse Executives (AONE) developed the Nurse Managers Competencies Framework to guide nursing schools in the development of their undergraduate and graduate curricula to successfully educate nursing students with essential management and leadership skills required in the performance of nurse manager roles. 3 These competencies include the following: resource management, management of patient care delivery, staff development, compliance with professional and regulatory standards, long-term and strategic planning, inter-professional management and leadership and collaboration with other units within the institution. 3

In many nursing schools, students are provided opportunities to imbibe skills in leading and managing when they attend a leadership and management course in the terminal year of their undergraduate nursing programme. However, facilitating and teaching leadership and management skills among nursing students remains a significant challenge to nursing faculty due to several factors such as increasing nursing student applications for admission, nursing faculty shortage and limited clinical placements to facilitate and integrate leadership concepts in clinical practice. 4 – 6 Unsurprisingly, many nurse managers and nurse executives perceive newly graduated nurses as not being sufficiently ready to perform leadership roles and responsibilities as well as lacking management skills when they start working as a professional nurse. 7

Alternative teaching approaches using simulations are vital to adequately prepare students for their future leadership roles as nursing professionals. Simulation is identified as a viable and supplementary teaching modality to facilitate the translation of theoretical concepts in nursing into practice. 8 , 9 The use of simulation is acknowledged as an indispensable aspect of the nurse education curriculum and has been widely used across all nursing courses. These include the following: Fundamentals of Nursing, Maternal and Child Health, Adult Health, Mental and Psychiatric Health, Community Health and Critical Care courses. 10 – 15 In particular, simulation studies have identified medium- to high-fidelity simulations as potent teaching modalities to foster students’ nursing competence, self-efficacy, critical thinking and reasoning, communication and interpersonal skills and clinical judgment. 16 – 21

Numerous nursing education institutions have supported the integration of simulation-based activities into their respective pedagogies. The National Council of State Boards of Nursing endorses the use of simulation-based activities as an alternative to usual clinical experiences to provide relevant and essential clinical experiences for nursing students. 22 The National League of Nursing supports the incorporation of simulation-based activities in nursing programmes to adequately prepare students for future nursing practice amidst the growing challenges in the field of healthcare.

Available evidence suggests that through simulation, nursing schools can help shape and develop management and leadership skills in students for future leadership and management roles. 23 Findings of Kilgore et al . and Sharpnack et al . showed that simulation experiences may enhance nursing students’ management skills such as prioritising and managing staff workloads, delegating, working with inter-professional health teams and making critical decisions. 24 , 25 While there is mounting evidence concerning the use and usefulness of simulation in teaching management and leadership courses, at present, this evidence does not present a wider viewpoint on this essential topic. This integrative review aimed to determine the outcomes of using simulation in pre-licensure nursing management and leadership courses.

An integrative review approach guided by the framework devised by Whittemore and Knafl informed this study. 26 This approach was deemed suitable as it allowed the combination of findings of studies with both experimental or non-experimental designs to provide a broader perspective on the topic.

To locate relevant articles published between 2008 and 2018, an electronic search of databases was conducted in January 2019. MEDLINE, Psych INFO, CINAHL and SCOPUS were used to locate and search for original articles using the following search and Medical Subject Headings terms: ‘management’, ‘leadership’, ‘simulation’, ‘nursing’, ‘education’ and ‘student’. Furthermore, a manual search of relevant literature was carried out based on the list of references in the articles included [ Figure 1 ].

Flowchart showing the selection process used to identify articles included.

The following inclusion criteria were considered in the search and retrieval of the articles: (1) original articles examining the use of simulation-based activities in teaching management and leadership skills in pre-licensure nursing programmes; (2) articles published in refereed journals within the last 10 years; and (3) articles written in the English language.

A total of 198 articles were retrieved during the initial search of the databases. After removing duplicates, 136 articles were retained. Titles and abstracts were further screened and compared using the inclusion criteria, with 45 articles being considered for full-text screening. Finally, 10 studies were considered appropriate for the review after a full-text reading of the articles; the remaining 35 articles were excluded because simulation procedures were either not clearly described, the processes were not purely simulation-based and contained studies or the participants were combined with others from a different healthcare profession [ Figure 1 ].

The quality, rigor, credibility and trustworthiness of the research methods used in the articles included in the review were examined using the Mixed Methods Appraisal Tool by two independent reviewers. 27 This appraisal tool was designed to assess the quality of studies (e.g. quantitative, qualitative and mixed-method studies). Based on the criteria set, a score was assigned that ranged from 25% to 100%. In this review, no articles were excluded based on the quality score due to a lack of studies that pertained to simulation as utilised in nursing leadership and management courses; instead, the tool was used to appraise the methodological quality of the articles reviewed.

Using a common template, essential data were extracted from the articles by two independent researchers, which included the authors, research design, subjects/simulation duration/debriefing duration, type of simulation/measures and key findings [ Table 1 ]. 7 , 24 , 25 , 28 – 34 Data were synthesised following the content analysis guided by the constant comparison approach. 35 Specifically, similar categories and subcategories were clustered by comparing each definition and the prevalence of certain themes was determined. Encompassing themes were discussed and further analysed by the researchers to arrive at common and most suitable theme names. This approach in data synthesis is compatible with an integrative review that includes studies with varied research methodologies to analyse and synthesise. 27

Summary of studies evaluating the use of simulation in teaching nursing leadership and management courses 7 , 24 , 25 , 28 – 34

SSLC = Student Satisfaction and Self-confidence in Learning Scale; CLECS = Clinical Learning Environments Comparison Survey.

STUDY CHARACTERISTICS

Based on the inclusion criteria, 10 articles published in the last 10 years were included in this review. The vast majority of the articles reviewed (n = 7, 70%) originated and were conducted in the USA and the remaining articles were from other countries such as Ireland, Australia and Canada. Six studies (60%) utilised a descriptive research design, two adopted a one-group pre- and post-test design, one employed a mixed-method design and the other used a two-group post-test design. 7 , 24 , 25 , 28 – 34 The sample sizes ranged from 24 to 155.

In the quantitative studies, some scales were utilised to measure outcomes of simulation such as the Student Satisfaction and Self-confidence in Learning Scale and the Clinical Learning Environments Comparison Survey (CLECS). 36 , 37 In four studies, a researcher-designed survey tool was used, while in one study (the Nursing Leadership Content Mastery Assessment) a standardised computer-based assessment tool, developed by Assessment Technologies Institute, was used. 38 Duration of simulation ranged from 20 minutes to 1.5 hours, while the debriefing duration ranged from 20 minutes to 1 hour. Concerning the quality score of the articles reviewed, the scores ranged from 80% to 90% out of a possible total score of 100%.

SIMULATION MODALITY AND SCENARIO

In this review, patient/clinical case scenarios employing high-fidelity mannequins, medium-fidelity simulators, low-fidelity simulators and used standardised patients during simulation. Simulation scenarios involved handling and caring for patients with various medical and surgical conditions including obstetric and gynaecologic, psychiatric, paediatric and gerontology patients. In articles with a control group, low- or medium-fidelity simulations or traditional clinical placements or demonstrations were used.

KEY FINDINGS

Four themes were identified from the content analysis: acquisition of skills or understanding of delegation, enhanced teamwork or collaboration capacities, improved decision-making and problem-solving skills and increased communication skills [ Figure 2 ].

Diagram of themes generated during the review.

ACQUISITION OF SKILLS OR UNDERSTANDING OF DELEGATION

Five studies determined the impact of simulation-based learning on nursing students’ acquisition of delegation skills and/or understanding of delegation. 24 , 25 , 29 , 32 , 34 Hourican et al . assessed the usefulness of simulation in promoting management skills in senior nursing students using high-fidelity mannequins and standardised patients. 34 Overall, nursing students reported higher levels of awareness and understanding in the following competencies: prioritising and managing staff workloads, effective delegation and maintaining patient safety. In Australia, students who were exposed to high-fidelity simulation expressed that the simulation experiences improved their skills in prioritising, delegation and time management. 32 Three studies in the USA yielded similar outcomes. 24 , 25 , 29 Nursing students who experienced simulation scenarios using medium-fidelity simulators and standardised patients obtained higher scores on delegation subscales when compared to those in non-simulation groups. 25 Similarly, an increased knowledge (n = 66, 68%) and higher confidence levels (n = 53, 55%) on delegating patient care and prioritising were seen in senior nursing students after simulation exposure. 29 In a descriptive qualitative study by Kilgore et al ., three essential themes emerged from the nursing student simulation evaluations: the nursing students felt that the experience was convincing, it fostered their ability to delegate and reinforced leadership and management concepts. 24

ENHANCED TEAMWORK OR COLLABORATION CAPACITIES

Another prominent theme that emerged from the content analysis was ‘teamwork or collaboration’ which was found in five studies. 24 , 25 , 29 , 32 , 34 In an Irish study, senior nursing students who were exposed to simulation scenarios using medium-fidelity simulators obtained higher scores in the following areas: providing support to colleagues, teamwork and interaction with the multidisciplinary team. 34 In one study that compared nursing students who had attended simulation activities, a significantly lower score in the ‘collaborate’ subscale of the Nursing Leadership Content Mastery Assessment was observed in students who had not attended simulation. 25 A similar finding was observed in an Australian study which identified improvements in the following competencies: time management, teamwork and strategies for prioritization. 32

Results of nursing students’ simulation evaluation, using a researcher-designed simulation-based learning exercise evaluation, showed higher levels of confidence in working as a team with nursing students who had attended a 20-minute simulation activity. 29 An important theme that emerged in the qualitative analysis by Kilgore et al . was an enhancement in nursing students’ ability to work within the healthcare team as well as reinforcement of leadership and management concepts learned in the classroom. 24

IMPROVED DECISION-MAKING AND PROBLEM-SOLVING SKILLS

Enhanced decision-making and problem-solving skills were identified as an essential outcome of the simulation. 29 , 31 Che’Reed et al . implemented a leadership management simulation in the USA in a group of students participating in a nurse leadership and management course. 28 After participation in a simulation scenario that involved a patient with severe incisional pain, the nursing students obtained a higher awareness of the following areas of nursing management: responding to emergencies, planning for addressing potential complications and making quick clinical decisions. Similar findings were observed in a descriptive study by Thomas et al . wherein out of 132 senior-level nursing students who had attended the simulation experiences, 95% expressed greater confidence in making ward/unit decisions, solving problems and critical thinking. 31

INCREASED COMMUNICATION SKILLS

The effects of simulation-based activities on students’ skills in communicating effectively with patients and the healthcare team were evaluated in three studies. 7 , 31 , 34 In a leadership simulation study by Hourican et al . using medium- and high-fidelity simulators and standardised patients, nursing students (after simulation) reported an increase in competence in communicating with colleagues and the other members of the multidisciplinary healthcare team, along with other competencies such as effectively working with the team, recognising professional and ethical issues, managing staff workloads and dealing with unforeseen events in the ward/unit. 34 In a descriptive study by Thomas et al ., there was a higher proportion of nursing students who attended a charge-nurse simulation scenario and expressed an increased knowledge of the charge-nurse role in collaborating and effectively communicating with the staff nurse subordinates and other healthcare team members. 31 In the USA, Gore et al . compared the efficacy of simulated and traditional clinical environments on leadership learning in nursing students. 7 After 30 to 40 minutes of simulation using low-fidelity mannequins, nursing students evaluated their simulation experience using the CLECS. Although the scores in the nursing leadership skills were equally high among the two groups, the communication subscales were significantly higher among nursing students who had attended the traditional learning placement when compared to nursing students in the simulation group. 7

This integrative review synthesised and appraised available literature examining the influence of simulation activities in fostering management and leadership skills among student nurses. A total of 10 studies, primarily with quantitative research designs, informed the findings of this review. While the researchers found some evidence that supported simulation as a modality in teaching management and leadership courses in nursing students, caution should be exercised when making inferences due to the scarcity of high-quality evidence.

Simulation studies demonstrated a positive influence of simulation-based activities for nursing students’ understanding or knowledge of and awareness of delegation. Delegation is a key function of a professional nurse and is defined as “the transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome”. 39 Ineffective delegation often leads to negative patient outcomes. 40 While delegation is considered an important nursing function, this skill often remains underdeveloped in newly graduated nurses and pre-licensure education is often accused of not adequately preparing nursing students to perform this essential role. 41 In a study in the UK, new nurses reported limited clinical opportunities to translate the concept of delegation into practice and to develop competencies to effectively supervise, manage and organise care during their pre-licensure nursing education. 40 Nevertheless, nursing faculty can strengthen delegation skills and facilitate the formation of delegation skills among nursing students; the simulation laboratory can be a good avenue to foster this skill.

Collaboration and communication emerged as important outcomes of simulation. The Inter-professional Education Collaborative recognised teamwork or collaboration and communication as an important component of a patient-centred care practice. 42 Available studies have identified the relevance of collaborative health practice, which is characterised by constant interaction, communication, collaboration and engagement among interprofessional healthcare workers along with patients and their families in attaining quality healthcare and positive patient outcomes, ultimately reducing costs of healthcare and improving organisational productivity. 43 , 44 Despite higher emphasis on the importance of effective communication and collaboration during the undergraduate programme, many new nurses expressed challenges in effectively communicating, collaborating and working with other healthcare teams, patients and their relatives. 45 , 46 This review’s finding supports international studies highlighting the essential role of simulation in enhancing collaboration, communication and teamwork among healthcare workers from different professions. 25 , 47

Furthermore, simulation showed a positive impact on nursing students’ abilities to solve problems and make critical decisions regarding patient care and ward/unit management. Problem-solving and decision-making are considered key processes in nursing. In particular, clinical decision-making among nurses is critically important when selecting interventions and treatments for patients and in addressing their needs. 48 According to Standing, decision-making skills, which is a central aspect of quality nursing care, can be developed during the undergraduate period to equip future nurses with the realities and challenges that they will encounter when they assume the professional nursing role. 49 However, many new nurses reported to be lacking in these essential skills and complained that their undergraduate education had not placed a high enough emphasis on this area of development. 46

Whereas all simulation studies showed potential in enhancing a variety of leadership and management competencies, caution should be exercised when making inferences due to the presence of certain methodological issues. For instance, most studies reviewed used either a descriptive design or a one-group pre- and post-test design. While many nursing and healthcare scholars have utilised pre- and post-test designs for research, unlike randomised control trials (RCTs), confounding variables that may affect the intervention outcomes are not or are poorly controlled. Conversely, findings of RCTs can generate high levels of evidence and are therefore useful as they can be used to guide policy implementers, healthcare managers and nurse leaders. Thus, future studies on simulation should be conducted utilising a more robust research design.

Another key observation was the lack of standardised scales in the included studies specific to measuring leadership and management skills in nursing students. Four studies utilised a researcher-designed survey tool and in the remaining studies outcomes of simulation were evaluated using the SSCL, the Nursing Leadership Content Mastery Assessment and the CLECS. Although these tools are validated, they are not specific to measuring leadership and management competencies in nursing students. As opined by Foronda et al ., evaluation of simulation efficacy using established instruments is critical. 50 This highlights the need for a simulation tool specific to measuring leadership and management skills in students. It is worth noting that leadership and management competencies and study subjects were evaluated using self-report tools rather than a direct measure of participants’ competencies. However, Baxter and Lederman suggested that self-reporting may not be an accurate measure of actual ability or performance; 51 thus, additional objective evaluation measures should be used to determine these essential competencies.

Power analysis or sample calculation is vital as sample size affects the transferability and generalisability of research findings. In this review, most of the studies included had inadequate sample sizes and none utilised a power analysis to identify the number of samples to be included to yield significant findings. In addition, the duration of the simulation-based activities varied significantly, ranging from 20 minutes to 1.5 hours, while the duration of debriefing ranged from 20 minutes to 1 hour. This certainly poses an inquiry as to how long a simulation activity should be delivered to nursing students to cause significant change in their knowledge and skills. Furthermore, simulation trainings of the simulation facilitators were rarely described. These factors should be considered in future simulation research as they may affect the outcomes of simulation and, thus, the generalisability of the findings.

Moreover, the studies reviewed originated mainly in the USA, Ireland, Australia and Canada. With the influx of foreign nurses from Asian countries (China, India and the Philippines) to Western countries (Canada, the UK and the USA), this finding poses a question with regard to the preparedness of these foreign nurses to assume nursing leadership roles. 52 It emphasises the importance of the integration of leadership simulation in the nursing curricula, especially in the abovementioned non-Western countries, to ensure that the nursing graduates from these curricula are prepared for future leadership and management roles and possess managerial and leadership competencies.

Despite the promising outcomes of leadership and management simulations, it is apparent that further efforts are needed when designing simulation activities that incorporate essential leadership and management competencies as defined by the AONE and are vital in the overall productivity and effectiveness of any healthcare organisation.

IMPLICATIONS FOR NURSING EDUCATION

This review’s findings highlight the value of simulation as a powerful tool in teaching leadership and management courses as well as the potential of enhancing certain leadership and management skills among nursing students. Amidst the increasing challenges being confronted in this regard by faculty, the incorporation of simulation into nursing management and leadership courses has the potential to enhance students’ skills pertaining to delegation, problem-solving and decision-making, communication and teamwork. Incorporation of simulation-based activities in nursing management, leadership courses and other nursing courses may be useful in the translation of theoretical knowledge into nursing practice. In doing so, nursing schools should ensure that nursing faculty have leadership expertise and are able to provide relevant leadership and management simulation courses or trainings to better support the learning needs of the pre-licensure nursing students. In addition, simulation resources should be provided to create a more realistic scenario necessary to deliver the intended learning outcomes.

This review provided up-to-date knowledge related to the current state of simulation-based activities in leadership and management courses in pre-licensure nursing programmes. The findings of this review support previous simulation studies underlining the significance of this teaching-learning method in enhancing a variety of nursing student outcomes.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

No funding was received for this study.

The perceived problem-solving ability of nurse managers

Affiliation.

• 1 Hacettepe University, School of Nursing, Ankara, Turkey. [email protected]
• PMID: 16787468
• DOI: 10.1111/j.1365-2934.2006.00551.x

Study rationale: The development of a problem-solving approach to nursing has been one of the more important changes in nursing during the last decade. Nurse Managers need to have effective problem-solving and management skills to be able to decrease the cost of the health care and to increase the quality of care.

Study aim: This descriptive study was conducted to determine the perceived problem-solving ability of nurse managers.

Method: From a population of 87 nurse managers, 71 were selected using the stratified random sampling method, 62 nurse managers agreed to participate. Data were collected through a questionnaire including demographic information and a problem-solving inventory. The problem-solving inventory was developed by Heppner and Petersen in 1982, and validity and readability studies were done. It was adapted to Turkish by Sahin et al (1993). The acquired data have been evaluated on the software spss 10.0 programme, using percentages, mean values, one-way anova and t-test (independent samples t-test).

Results: Most of the nurses had 11 or more years of working experience (71%) and work as charge nurses in the clinics. It was determined that 69.4% of the nurse managers did not have any educational training in administration. The most encountered problems stated were issues related to managerial (30.6%) and professional staff (25.8%). It was identified that nurse managers who had received education about management, following scientific publication and scientific meeting and had followed management models, perceived their problem-resolving skills as more adequate than the others (P>0.05).

Conclusion: In this study, it was determined that nurses do not perceive that they have problem-solving skills at a desired level. In this context, it is extremely important that this subject be given an important place in both nursing education curriculum and continuing education programmes.

• Analysis of Variance
• Attitude of Health Personnel*
• Chi-Square Distribution
• Education, Nursing, Continuing
• Health Knowledge, Attitudes, Practice
• Health Services Needs and Demand
• Hospitals, Public
• Hospitals, University
• Middle Aged
• Nurse Administrators / education
• Nurse Administrators / psychology*
• Nurse's Role / psychology
• Nursing Evaluation Research
• Nursing Methodology Research
• Nursing Process
• Personality Inventory
• Problem Solving*
• Professional Competence / standards*
• Self Efficacy*
• Self-Assessment
• Statistics, Nonparametric
• Surveys and Questionnaires