How does the nurse manager or leader play a role in the re engineering of health care?
Re engineering Health Care
Decisions based on ethical and legal principles are common in a person’s life. Choices such as whether
to indulge in gossip (breaching confidentiality) or driving too fast on the highway are examples of
these decisions. Making good ethical and legal decisions in nursing management or leadership practice
requires understanding of the underlying principles and incorporating that knowledge into the
Ethical decision-making is similar to other decision-making processes in that it requires the manager to
gather information, identify the problem, generate alternatives, or select an alternative to implement,
and evaluate the results. The difference in ethical decision-making depends on the identification of the
ethical principles that guide the selection and expectations of the outcome.
The principles underlying ethical decision-making include concepts that are familiar to practicing
nurses. Is it best for the nurse to use specialized knowledge to make decisions for a patient
(paternalism) or to support patients in making their own decisions (autonomy)? Are there circumstances
in which the need to benefit the majority of staff (utility) outweighs the need to treat everyone fairly
(justice)? Is telling a white lie (violating the principle of truth-telling) justified when it is
believed that the withholding of the truth will benefit the recipient (beneficence)? These are the
competing obligations that create ethical dilemmas. Ethical decision-making requires the identification
of competing principles as a part of describing the problem.
Ethical frameworks and professional codes of ethics exist to assist the manager in ethical
decision-making. Both frameworks and codes provide guidance in valuing one principle above another, but
do not directly provide the solution. There are several ethical frameworks. Two commonly used frameworks
are utilitarian-based and rights-based. A utilitarian framework advocates selecting an alternative that
will result in the greatest good for the greatest number of people, focusing on the projected outcome.
An example of using a utilitarian framework is the isolation of a patient with a communicable disease.
Although this isolation infringes on the person’s autonomy, the common good (utility) of not spreading
the disease is served. A rights-based framework focuses on the process of decision-making and
utilization of identified rights or entitlements. This type of framework is evident in The Bill of
Rights for Registered Nurses (The American Nurses Association, n.d.).
Professional codes of ethics have been published by several professional nursing organizations. These
codes generally support the principles of autonomy, justice, and beneficence, but they also acknowledge
that there are times when competing obligations may require the nurse to select alternatives based on
Ethical decision-making is also unique in that it often entails choosing among less than desirable
alternatives. The outcome of the decision may not be judged as good but as better than other outcomes.
When evaluating the outcome of ethical decision-making, reviewing the process used to make the decision
is as important as the result (Marquis and Huston, 2009).
Legal Environment in Nursing Management
Ethical frameworks and codes of ethics provide guidance for decision-making, but are not required. Laws
are written to support the values and ethics of society, requiring citizens to act in a certain manner
or face the consequences in a court of law. There are wide ranges of laws that affect the practice of a
nurse manager. Legislation directly affects both patient care and professional relationships with
Patient care related legislation primarily supports patient autonomy. Laws exist to require informed
consent prior to performing a procedure on a patient. This allows patients to make informed choices
regarding their health care. Ignoring informed consent can lead to charges of assault and battery
(causing the patient to feel threatened or touching the patient who has not consented). The unwarranted
use of restraints can constitute false imprisonment. The nurse manager is responsible for ensuring that
organizational policies provide guidance to staff in avoiding these legal issues. The HIPAA Standards
for Privacy of Individually Identifiable Health Information Act supports patient confidentiality by
regulating how and when an individual’s information may be shared (U.S. Department of Health and Human
Legislation that affects employee relations covers general topics such as discrimination and fair labor
laws. In general, anti-discrimination laws require that all employees be treated fairly. The requirement
that employees speak English only in the workplace is an example of a potential source of national
discrimination (Lewis, 2004). Policies must be carefully written to meet legal requirements while
allowing the organization to fulfill its mission. It is fundamental to seek legal advice when addressing
sensitive policy issues.
Particular to the nurse manager are laws that relate to the professional scope of practice for licensed
and unlicensed health care workers. Nurses in management positions are responsible for assuring that
employees maintain required professional licensure, practice within their scope, and maintain competence
in their practice. Providing feedback and disciplinary measures for staff that are violating these
practices are an important part of the management role (Marquis and Huston, 2009). Appropriate
delegation of duties falls within this realm as well; staff must not be required to practice outside
their scope or provide care in which they are not competent.
Keeping abreast of the legal environment is imperative for the nurse manager. Collaboration with human
resources and legal professionals will assist the manager in maintaining compliance with current laws.
Advocating for Patients and Staff
Nurses in management and leadership positions frequently find themselves in the role of advocate for
both patients and staff. Advocacy is a process used to facilitate growth in others. Common methods of
advocacy are: 1) providing others with information that empowers them to make their own decisions, and
2) acting on behalf of others who do not have the ability or power to advocate for themselves. Care must
be taken to ensure that advocacy remains focused on supporting decision-making, rather than making
decisions for others.
The nurse manager advocates for patients by developing a unit culture that promotes respect for patients
and their ability to make decisions, even if those decisions are different from the ones the staff
members would make. Patient education is one method of empowering patients; the manager ensures that
both the materials and time are available for this nursing function. The manager can also listen to
staff as they converse about patients and provide feedback on instances of respectful or disrespectful
Staff concerns may also require the nurse manager to act as an advocate within the organization. Issues
arising from staffing levels, care delivery, and the need for professional development may not be as
highly valued by the organization. The nurse manager, using the power of the position, can often be more
effective than individual staff members in fulfilling the advocacy role.
Beyond the organization, there are numerous initiatives that benefit from nurse advocacy. Patient safety
and access to care are among these initiatives. The role of the individual nurse is important; however,
Welchman and Griener (2005) make a case for greater involvement of professional organizations in the
advocacy role. They argue that since professional organizations have greater power to effect change than
individual nurses, that advocacy should be a larger part of their mission.
The most important and most difficult skill for a leader is the ability to listen. Leaders must listen
to the sounds of change. Leaders must help people work through the grieving process and conflicts
experienced during time of change. Because the pace of change in health care is so rapid, leaders must
be prepared to deal with the chaos and uncertainty through calm communication. The focus for this week
will be on change management, problem solving, conflict resolution, and communication methodologies for
dealing with crises.
In the good old days, change came slowly and was predictable. Today, change happens so quickly that it
is sometimes difficult to realize when one change has been completed and another change has begun.
Often, more than one change is happening at the same time, and people are adapting to multiple changes
at once. One of the contributing factors to this rapid change is the availability of information.
In the 20th century, knowledge was treated as a possession. One had knowledge or gained knowledge. The
process of learning was essentially a process of stuffing facts into one’s head. As a result of this
process, the knowledgeable person possessed knowledge and could draw from it when necessary. Our modern
existence has led us to view knowledge as a utility. Because so much information is available, no one
could ever have sufficient capacity to acquire all the knowledge he or she will need. Thus, the focus
has shifted from possession to access (Porter-O’Grady and Malloch, 2002, p. 42).
The only thing constant in this world is change. Longstanding contracts are being broken. Employment for
life and even employer loyalty are outdated concepts, meaning that organizations will change. If
organizations are to survive, adaptation to change is essential. The key to comfort in change is to try
out the new before giving up the old by getting those affected by the change involved. Wilson and
Porter-O’Grady (1999) describe the best scenario as “solid growth and partial stability” (p. 275).
Leaders have the difficult task of helping others to move towards change while tempering the movement so
that it does not move too fast. Managing change is really about helping people maintain or enhance their
self-esteem through the period of transition.
So, how should change be managed? Following these steps will help a leader with transitioning to the
next level of understanding:
1. Analyze the need for change.
2. Create a shared vision and common direction.
3. Separate from the past.
4. Create a sense of urgency.
5. Support a strong leader role.
6. Develop an implementation plan.
7. Develop structures that support the change.
8. Communicate, involve people, and be honest.
9. Reinforce the change.
10. The hardest phase of change is maintenance. Adult learners need constant reinforcement until the
change becomes a habit.
Conflict is often perceived in a negative manner, yet it is a normal and essential component to human
interaction. Intelligent leaders realize that conflict can cause change and that this change may be a
positive move for an organization. When conflict is present, differing views emerge from stakeholders.
The presence of these views forces out-of-the-box discussions and dialogue. “The truth is that everyone
who comes together brings with him or her insights, perspectives, views, experiences, and life
applications that are specific and unique to the individual participant” (Wilson and Porter-O’Grady,
1999, p. 417). Recognizing the strength in diversity and having the insight necessary to manage
conflict is a critical skill for health care leaders.
Conflict resolution is made up of the processes by which the parties involved achieve an agreement where
all participants have an advantage. The purpose of the leader in conflict is to facilitate or mediate
and assist the parties to a resolution of the issue through common ground. Some of the questions the
leader might ask include:
1. What is the key issue in the conflict?
2. At what point did the conflict emerge?
3. What are the individual views of each stakeholder?
4. What are the barriers to resolution?
5. How does each participant envision the final outcome?
An important mission for the leader is to make sure that each participant understands the issues of the
other person, that all perceptions are clarified, and that there is a common understanding for an
Communicating During Crisis
Conflict is often precipitated by a surprise crisis which is usually viewed as negative and causes
distorted perceptions and disruptions. Communication is a key factor in response to any crisis.
Effective communication helps to provide direction and disseminate information while maintaining
Before a crisis occurs, leadership should be briefed on the defined communication chain and logistical
details. Brainstorming can be a proactive action to crisis. The plan should include information such as
names, phone numbers, availability, inventory, availability of equipment, parking, staff, and
anticipated written material for media.
During a crisis, leaders should debrief frequently. Questions that should be answered include:
1. Who are the stakeholders?
2. How, when, and where did the problem begin?
3. What is happening now?
4. What are the possible scenarios through which the situation will play out?
5. What are the legal and ethical ramifications?
6. Has this happened before? If so, how was it handled?
Coordinating communication is imperative to the stability of the people within the organization.
Internal and external audiences will be present and might include the media, family members, visitors,
patients, and employees. Leaders should strive to communicate only the facts, deal with rumors swiftly,
and document crises in writing so that there will be an inventory and record of the event. When a crisis
is over, a debriefing should help identify areas of strength, areas of weakness, and a follow-up plan.
Ethics and legal principles provide the foundation for the practice of management in nursing and the
role of advocacy. Historically and currently, many issues in health care, such as the movement to
improve patient safety, have both ethical and legal implications. The American Nurses Association (ANA)
Code of Ethics (2005) requires nurses to be advocates for their patients, ensuring that patients have a
voice in their care, and that their decisions are respected. Additionally, nurse managers must ensure
that staff members have a voice in the workplace that empowers them to advocate for patients and for
Conflict and change are inevitable. Good leaders are always on the edge of chaos, looking over the
horizon, looking just beyond the precipice, and they are able to read, interpret, and express what they
discern when situations arise. Their real gift is their ability to walk back to where those they lead
are living and translate what they have seen into a language that has force and meaning for those who
can hear it. They then have the job of getting behind the staff and pushing them into their own
definition of the emerging reality, allowing the staff to own what they see and act on it in a
responsive and viable way (Porter-O’Grady and Malloch, 2002, p. 36). Leadership’s role is to tame the
change, control the conflict, and manage the communication.