Nursing Leadership & Management: Decision-Making and Theory Reviewer Leadership Models and Historical Management Theory

Decision-Making, Problem Solving, Critical Thinking, and Clinical Reasoning

  • Decision-making is a complex, cognitive process often defined as choosing a particular course of action. It is often synonymous with management and is one of the criteria on which management expertise is judged.
  • Decision-making is defined as the thought process of selecting a logical choice from the available options. It implies that doubt exists about several courses of action and that a choice is made to eliminate uncertainty. While usually triggered by a problem, it is often handled in a way that does not focus on eliminating the underlying problem.
  • Problem solving is a systematic process that focuses on analyzing a difficult situation and is considered part of decision-making. Problem solving always includes a decision-making step. In this process, significant time and energy are spent identifying the root problem to solve it at its source.
  • Critical thinking, also known as reflective thinking, has a broader scope than decision-making and problem-solving. It is defined as disciplined thinking that is clear, rational, open-minded, and informed by evidence. It involves higher-order reasoning and evaluation, featuring both cognitive and affective components.
  • Components of critical thinking include:
    • Insight
    • Intuition
    • Empathy
    • Willingness to take action
  • Clinical reasoning occurs when nurses integrate and apply different types of knowledge to weigh evidence, think critically about arguments, and reflect on the process used to arrive at a diagnosis.
  • Elastic thinking arises from bottom-up processes involving individual neurons firing in a complex fashion with input from the brain’s emotional centers rather than high-level executive structures. This nonlinear processing allows individuals to solve novel problems, overcome neural and psychological barriers, and produce creative ideas that step-by-step analytical thinking might miss.

Vicarious Learning to Increase Management Skills

  • Successful decision-making and problem-solving can be learned through life experience, but trial-and-error methods are inefficient because they leave much to chance.
  • Case studies are stories used to impart learning. Those that unfold over time provide interactive learning experiences and assist in the retention of didactic materials by allowing learners to identify with the situations.
  • Simulation allows learners to practice problem solving with little or no risk to patients or organizational performance. Discrete event simulation uses computers to imitate real-life systems like hospitals. Performance in simulations provides insight into the quality of decision-making based on priority setting, timeliness, and outcomes.
  • Problem-Based Learning (PBL) involves meeting in small groups to address and learn from authentic, real-life problems. This collaborative, active learning approach helps develop critical thinking skills under the guidance of a teacher.
  • The Marquis-Huston Critical Thinking Teaching Model suggests that learning occurrs best in groups using PBL. It focuses on the ability to critically examine management issues and learn appropriate social/professional behaviors. It consists of four overlapping spheres:
    • Didactic theory (material presented in chapters).
    • A formalized approach to problem solving and decision making.
    • Group process (classroom discussion, small and large groups).
    • Internalization of material through writing exercises, personal exploration, values clarification, and risk-taking.
  • Experiential learning exercises include case studies, budgeting calculations, staffing problems, and assessments of personal attitudes to apply leadership theory Mock experiences provide tremendous value in bridging theory and practice.

Theoretical Approaches to Problem Solving

  • Heuristics are practical mental shortcuts, trial-and-error methods, or rule-of-thumb approaches. They provide immediate solutions in uncertain or emergent situations where knowledge and time are limited, though they do not guarantee perfect or optimal results.
  • Anchoring bias is a heuristic where an initial source of information acts as an anchor for decision-making. This can lead to medical errors, inappropriate resource use, and patient harm.
  • The Traditional Problem-Solving Process consists of seven steps:
    1. Identify the problem.
    2. Gather data to analyze causes and consequences.
    3. Explore alternative solutions.
    4. Evaluate alternatives.
    5. Select appropriate solution.
    6. Implement the solution.
    7. Evaluate the results.
    • A weakness of this model is the significant time needed for implementation and the lack of an initial objective-setting step.
  • Managerial Decision-Making Models (Rational Models) address traditional weaknesses by adding an objective-setting step. The six steps are:
    1. Determine the decision and desired outcome (set objectives). This involves identifying the timeline, goals, and participants.
    2. Research and identify options (generate as many alternatives as possible).
    3. Compare and contrast options and consequences. Often involves SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis or quantitative tools.
    4. Make a decision (rank alternatives based on analysis).
    5. Implement an action plan.
    6. Evaluate results (managing risks and comparing outcomes against step 11 objectives).
  • The Nursing Process was developed by Ida Jean Orlando in the late 19501950s. Originally a four-step model (assess, plan, implement, and evaluate), it now usually includes five steps (assessment, diagnosis, planning, implementation, and evaluation).
    • Its strength is the multiple venues for feedback.
    • Its weakness is that it does not always require clearly stated objectives, which may be omitted in the planning phase.
  • Integrated Ethical Problem-Solving Model provides a structured approach involving:
    1. Determining if an ethical issue or dilemma exists.
    2. Identifying key values and principles.
    3. Ranking central values or principles.
    4. Developing an action plan consistent with ethical priorities.
    5. Implementing the plan using appropriate practice skills.
    6. Reflecting on the outcome.
  • Intuitive Decision-Making Models acknowledge that experienced nurses use gut-level feelings to guide action. The Recognition-Primed Decision (RPD) model, developed by Klein in the mid-19801980s, explains how decisions are made under time pressure and uncertainty. It blends intuition and analysis, where individuals act on their first impulse if an "imagined future" looks acceptable. If not, the subconscious provides another concept for examination.

Critical Elements in Problem Solving and Decision Making

  • Define objectives clearly: Even in emergencies, pausing to reflect on the purpose of a decision prevents poor-quality choices inconsistent with one’s philosophy.
  • Gather data carefully: Information seeking should be active. One must beware of confirmation bias, which is the tendency to search for and favor information that confirms existing beliefs while devaluation contradictory data.
  • Questions for data gathering:
    • What is the setting and what is the problem?
    • Where is the problem and who is affected?
    • What is happening and why? (Identifying causes and underlying issues).
    • What are the consequences? (Prioritizing the most serious).
  • Take the necessary time: Trivial decisions can be quick, but slower, controlled deliberation is needed for significant consequences. Taking 3030 minutes vs. 55 minutes can lead to a better understanding of nuances and fewer mistakes.
  • Use an evidence-based approach: Best practices are research-based. The PICO format (Patient/Population, Intervention, Comparison, Outcome) guides the search for evidence. Strategies for the new nurse include:
    • Subscribing to professional journals and reading widely.
    • Using evidence for clinical interventions and teaching strategies.
    • Challenging nursing traditions not supported by evidence.
    • Collaborating locally and globally.
  • Generate numerous alternatives: Decisions imply at least two choices, one of which is doing nothing (maintaining the status quo). Brainstorming helps break through habitual thinking.
  • Think logically: Inferences are part of deductive reasoning. Logical fallacies to avoid include:
    • Overgeneralizing: Believing every AA has a characteristic because one AA has it.
    • Affirming the consequences: Deciding that if BB is good, existing AA must be bad.
    • Arguing from analogy: Assuming because AA is present in BB, then AA and BB are alike in all respects.
    • Both-sidesing: Giving false equivalence to a flawed idea by presenting two sides as equally valid.
  • Choose and act decisively: Decisions are rarely cast in stone, but they must be made to develop improved skills.

Individual Variations in Decision-Making

  • Sex and Brain Anatomy:
    • Men are more likely to make extreme choices than women.
    • Frontal lobes (problem solving) and limbic cortex (emotions) are larger in women.
    • Men have approximately 6.56.5 times more gray matter; women have about 1010 times more white matter.
    • Women may use white matter to process information faster.
  • Values: Every decision is based on a value system, either consciously or subconsciously.
  • Life Experience: Maturity and a broad background allow for the identification of more alternatives.
  • Individual Preference: Decision makers may prioritize safety over risk based on personal physical, economic, or emotional costs.
  • Brain Hemisphere Dominance:
    • Left-brain: Analytical, linear, logic, and numbers.
    • Right-brain: Creative, intuitive, nonverbal ideation.
    • Ned Herrmann’s Four Brain Dominance Styles:
    • Upper-left: Analytical thinkers, logical, rational, factual.
    • Lower-left: Highly organized, detail-oriented, value security over risk.
    • Upper-right: Big-picture thinkers, futuristic, rely on intuition, take risks.
    • Lower-right: Emotional thinkers, sympathetic, empathetic, focus on interpersonal aspects.

Overcoming Individual Vulnerabilities

  • Periodically examine personal values.
  • Use available resources, such as research literature.
  • Involve mentors, colleagues, and experts as advisors.
  • Conduct retrospective analysis of decisions to learn from mistakes.
  • Be honest about preferences and willing to take risks.
  • Use group processes to ensure both analytical and intuitive perspectives are considered.

Decision-Making in Organizations

  • Organizational power: Powerful individuals influence decisions to align with their own values and can inhibit the preferences of those with less power. This often results in employees adopting an "organizational personality."
  • Rational vs. Administrative Decision-Making:
    • Economic Man: Makes rational decisions, has complete knowledge of the problem, considers all alternatives, and maximizes utility.
    • Administrative Man: Knowledge is fragmented, consequences cannot be perfectly predicted, and only some alternatives are considered. Final choices are satisficing (good enough) rather than maximizing.
  • Quality of decisions should not be judged merely on outcomes, as some facts may be hidden or choices with high success probability may still fail. Decision-making is the calibration among "shades of gray."

Decision-Making Tools

  • Decision Grids: Visually compare alternatives against the same criteria. Numerical values can be assigned to weigh criteria.
  • Payoff Tables: Help when quantitative data is available to determine a cost-profit-volume relationship. For example, calculating the break-even point for an in-service program where an instructor costs $500\$500. At 2020 participants the cost is $25\$25 each; at 4040 participants it is $12.50\$12.50.
  • Decision Trees: Used when decisions are tied to outcomes of other events, such as comparing the cost of hiring regular staff vs. on-call staff depending on procedural volume.
  • Consequence Tables: List objectives on one side and rate alternatives against them (e.g., evaluating fall-prevention programs based on cost, policy, and effectiveness).
  • Logic Models: Pictures of how programs operate, showing relationships between resources, processes, and outcomes.
  • Program Evaluation and Review Technique (PERT): A flowchart tool used to determine the timing of activities. It identifies the "critical path" which is a sequence of events that must occur before one can proceed.
  • Pitfalls: Common flaws include basing decisions on first impressions, confirmation bias, and allowing past events to unduly influence current choices.

Distinctions Between Leaders and Managers

  • A manager organizes; a leader innovates.
  • A manager relies on control; a leader inspires trust.
  • A manager asks "how" and "when"; a leader asks "what" and "why."
  • Managers create a circle of power; leaders create a circle of influence.
  • Managers direct subordinates (willing and unwilling); leaders direct willing followers.
  • Managers emphasize productivity and result analysis; leaders emphasize interpersonal relationships and empowerment.
  • Leadership inspires change; management manages transformation.
  • Managers are assigned a position; leaders may or may not part of the formal hierarchy.

Historical Development of Management Theory

  • Scientific Management (1900−19301900-1930): Frederick W. Taylor. Focused on finding the "one best way" to increase productivity. Principles:
    1. Replace rule-of-thumb with scientific methods (time/motion studies).
    2. Scientific personnel system (hiring based on competence).
    3. Workers see how they fit into the mission (financial incentives for production level).
    4. Cooperative relationship between managers (planning) and workers (doing).
  • Bureaucracy (19221922): Max Weber proposed strict rules, regulations, and formal authority to increase organizational efficiency.
  • Management Functions: Henri Fayol identified planning, organization, command, coordination, and control. Luther Gulick expanded this to POSDCORB (Planning, Organizing, Staffing, Directing, COordinating, Reporting, Budgeting).
  • Five Current Management Process Steps:
    1. Planning: Philosophy, goals, projections, fiscal action.
    2. Organizing: Structure, power/authority, care delivery grouping.
    3. Staffing: Recruiting, hiring, scheduling.
    4. Directing: Human resources, motivating, conflict management, delegating.
    5. Controlling: Performance appraisals, fiscal accountability, quality control.
  • Human Relations Management (1930−19701930-1970):
    • Mary Parker Follett: Advocated for "authority with" rather than "authority over" employees (participative management).
    • Hawthorne Effect (Elton Mayo): Productivity increases when management pays special attention to workers.
    • Theory X and Y (Douglas McGregor): Theory X managers view workers as lazy needing constant supervision; Theory Y managers view workers as self-motivated and hard-working.
    • Chris Argyris: Stated that managerial domination discourages workers and stressed the need for flexibility and employee participation.

Evolution of Leadership Theory

  • Great Man/Trait Theories (1900−19401900-1940): Asserted that leaders are born, not made, and study prominent figures to identify desirable traits.
  • Behavioral Theories (1940−19801940-1980): Focused on leadership styles.
    • Authoritarian: Strong control, motivated by coercion, downward communication, punitive criticism. High productivity, low creativity.
    • Democratic: Less control, motivated by awards, upward/downward communication, "we" emphasis, constructive criticism. Promotes growth but can be less efficient.
    • Laissez-faire: Hands-off, little control, permissive, communication between members. Can lead to group apathy but encourages creativity in self-directed groups.
  • Situational/Contingency Theories (1950−19801950-1980):
    • Law of the situation (Follett): Situation determines directives.
    • Contingency approach (Fiedler): No single style is ideal; influenced by leader-member relations and task.
    • Situational leadership theory (Hersey and Blanchard): Style changes based on follower maturity; moves from task-focused to relationship-oriented as they mature.
  • Interactional Leadership (19701970-Present):
    • Schein's Model: Humans are complex beings in open systems; performance is affected by task nature, ability, and motivation.
    • Hollander: Saw leadership as a dynamic two-way exchange between the leader, follower, and situation.
    • Theory Z (Ouchi): Consensus decision-making, job security, holistic concern for workers.
    • Kanter: Empowerment through formal and informal organizational systems (opportunity, power, and proportion).
  • Transactional and Transformational Leadership (Burns):
    • Transactional: Focused on day-to-day operations.
    • Transformational: Committed, visionary, empowers others. Requires pairing with transactional skills for success.
  • Kouzes and Posner’s Five Practices:
    1. Modeling the way (value clarification).
    2. Inspiring a shared vision.
    3. Challenging the process (taking action).
    4. Enabling others to act (power sharing).
    5. Encouraging the heart (celebrating followers).
  • Full-Range Leadership (Bass and Avolio): Adapting between transformational, transactional, and laissez-faire styles based on the given context.

Twenty-First Century Leadership Thinking

  • Strengths-Based Leadership: Focuses on empowering strengths rather than fixing weaknesses. The four leadership domains are Strategic Thinking, Influence, Relationship Building, and Execution. Followers seek four things: Trust, Compassion, Stability, and Hope.
  • Appreciative Leadership: Relational approach focusing on recognizing potential and building on strengths through appreciative inquiry.
  • Level 55 Leadership (Jim Collins):
    • Level 1: Highly Capable Individual.
    • Level 2: Contributing Team Member.
    • Level 3: Competent Member.
    • Level 4: Effective Leader.
    • Level 5: Great Leader (Unique blend of humility and will).
  • Servant Leadership (Robert Greenleaf): Priority is serving others (employees, customers, community). These leaders listen deeply, deal with ambiguity, use foresight, and nurture follower growth.
  • Principal Agent Theory: Agents (followers) may have informational advantages and preferences that deviate from the Principal (leader), requiring incentives for agents to act in the organization's interest.
  • Human and Social Capital: Employees are assets. Human capital is collective individual skills/knowledge; Social capital is the relationship network based on reciprocity and trust.
  • Emotional Intelligence (EI/EQ):
    • Three processes: Appraising/expressing, regulating, and using emotions in adaptive ways.
    • Goleman’s Five Components: Self-awareness, Self-regulation, Motivation, Empathy, and Social skills.
  • Authentic/Congruent Leadership: Integrity between professing values and acting on them. Leaders must be true to themselves.
  • Thought Leadership: Individuals who convince others to consider innovative, future-oriented ideas through risk-taking and passion.
  • Rebel Leadership (Francesca Gino): Encouraging novelty, curiosity, and constructive dissent to break traditions and explore new ideas.
  • Agile Leadership: Inclusive, democratic, and flexible. Ability to adapt quickly and ask powerful questions to help the organization move forward.
  • Quantum Leadership: Environment is complex, dynamic, and paradoxical. Change is constant; leaders must resolve conflicts in the "unsettled space" between the present and future.
  • Transition to Relationship Age Leadership: A paradigm shift from top-down industrial structures to focusing on the personal and professional development of followers.
  • Efficiency (Stephen Covey): The balance between Production (results) and Production Capability (maintaining efficiency).
  • Tamara McCleary’s Steps for Engagement:
    1. Invest time and care in employees.
    2. Monitor qualitative data (trust, happiness) alongside metrics.
    3. Evaluate progress in the "big three": engagement, service, and results.