Formal and Informal Decision Making
Organizations have many task forces, councils, and committees that are designed to contribute to the success of the organization and improve its function. Describe one of these groups, discussing the formal and informal leadership, how decisions are made, and what the role of those that are most influential have on the final product or outcome of the group’s efforts.
Nursing Services Delivery Theory (NSDT)—An Open System
Several systems theories discovered in the literature, including open systems, chaos, and multiple types of adaptive theories, may assist in leading nursing services (Rose, 2013). The open systems approach will be our focus here, as we look at how healthcare organizations meet their needs in various areas. Some of the areas that leaders deal with daily are finance, quality, and regulatory requirements.
Systems can be closed or open. A closed system has inputs and outputs within distinct barriers; most often, these barriers are from the internal organizational environment. The closed system is seen as an entity wherein all the components for functioning are within the system; there are no inputs or outputs from the external environment. Historically, healthcare has been considered a closed system.
An open system is seen as an entity that is interactive with its environment, being sustained by the inputs and outputs of the system. In open systems, there is a hierarchy in which smaller systems interact with each other dynamically to support goals or accomplish tasks (Sullivan, 2011). Some of the smaller units of the healthcare system include highly specialized areas such as the emergency department and the intensive-care unit; the laboratories and central processing; and human resources and financial management. An open organization becomes more complex as more specialized units are developed and function within it. In an open system, all the units are interdependent. Leaders have a broad overview and understanding of the system within which they work as well as a detailed view of the areas within their sphere of influence. The healthcare open system functions to create patient care, diagnosis, and treatment for patients, and provide all the intricacies to support this goal.
Inputs, Throughputs, Outputs, Cycles of Events, and Negative Feedback
In NSDT, there are four main components that nurse leaders must consider in their daily work; these are inputs, throughputs, outputs, cycles of events, and negative feedback. The inputs are the people, materials, resources, and information. The people are all those who are internal and external to the system, including staff and patients. Materials mean those items that are required to complete the organizational goals of care delivery, such as supplies and devices. The resources are related to funding sources such as insurance, government, grants, loans, and donations. Information is vast, ranging from the overall climate of the external environment to the details related to a specific patient (Meyer & O’Brien-Pallas, 2010).
Throughput is what is manipulated and changed to affect us reaching our goal. Throughputs can be as simple as a nursing intervention and other provisions of services (Meyer & O’Brien-Pallas, 2010). Outputs are those things that include any products generated (perhaps through research), materials created (such as a new device or drug), and services provided. One clear service that is provided as an output is the volume of patients that are cared for. One product is the revenue that is generated within the organization.
Systems cycles are those regular and periodic events that ensure best practices, highest quality, and patient safety such as adherence to regulatory demands (Meyer & O’Brien-Pallas, 2010). Other cycles include infection-control data and monitoring, review and updating of policies and procedures, and addressing patient-satisfaction surveys.
Negative feedback has high appreciation from nursing leaders because this is a mark of the degree to which their sphere of influence is meeting organizational expectations (Meyer & O’Brien-Pallas, 2010). Negative feedback occurs through evaluation of performance indicators for the organization and those people and specific units functioning within it.
An example of how the NSDT works within the organization is seen by observing a nursing unit’s activity. The patient arrives for care, leading nursing staff to input the delivery of services to promote the output of improved patient health. Along this path, there may be necessary changes in room assignment or areas of care; these changes would be throughput, and during this change, there may be negative feedback if the patient and family do not appreciate the change.
It is through the use of the NSDT and consideration of healthcare as an open system that leaders gain information and insight into how to respond to daily events that bring barriers and challenges to the organization’s function and meeting the goals for patient-care delivery.
System Unit Interdependence
Leaders must keep the organizational goals firmly in mind as they work within the organization creating changes (throughput) to improve the output. Daily staffing of the organization in which staff assignments are adjusted across units is a keen example of how throughput is used, demonstrating the interdependence of systems units on each other. Consider the oncology unit with the need for two registered nurses due to high patient volume. The goals of the organization must be met, including delivery of high-quality, safe patient care to all patients on the oncology unit. Leaders evaluate staff competencies and change (throughput) the nursing care assignments of two registered nurses from one area to another. If this shortage of nursing personnel becomes an ongoing situation, the organization will adapt by hiring additional registered nurses in a supportive role for the oncology patient population. Leadership will evaluate the department performance, and should the number of patients decrease, the oncology registered-nurse staff would shift to accommodate the needs in another area (throughput). A cycle of events for this particular oncology unit may occur seasonally if there is an influx of population such as in a college town or a city where the weather is pleasant during a harsh winter. Feedback will be obtained from staff and patients and, if negative, additional adjustments will be made by the leadership team. Thus nursing services delivery is a dynamic interplay of inputs, throughputs, outputs, cycles of events, and negative feedback.
Why NSDT Is Important
Although the use of the NSDT seems to organize the work within the environment, there continue to be many variables that impact the ability to ensure consistency in delivery of nursing services. These variables include the patients who are different ages, genders, cultures, degrees of illness, and degrees of needs. Some tools are available to leaders who strive to create the steady state for patients and employees, but often there is more chaos than consistency.
Using the NSDT as a foundational component, leaders can focus on both the global and sub-units of the organizational system. The NSDT allows leaders to measure and evaluate nursing services through observing the actual work completed rather than using data that may not offer both quantitative and qualitative perspectives. Unlike the closed system, open systems described through the use of the NSDT are energetic, innovative, and dynamic in the approach to nursing services. Applying the NSDT with nurse-sensitive indicators supports leaders to lead and manage the process of nursing within the organization (Meyer & O’Brien-Pallas, 2010).
Emotional Intelligence in Leadership
As leaders use the NSDT to gain information and insight within their organizations, it becomes important for these leaders to manage their behaviors and communication in a manner that is appropriate for their roles. In order to ascend to the highest levels of leadership, individuals must be able to view, know, and reflect on their behaviors and communication patterns related to the impact on others. There are five components to emotional intelligence. These are (a) self-awareness, (b) self-regulation, (c) motivation, (d) empathy, and (e) social skills (Taft, 2013).
Self-awareness is the component that identifies the degree to which the leader knows him- or herself. This is the ability to know what you are feeling and how these feelings may translate in facial expression, body language, and verbal communication and how others in the environment will interpret and respond to you. Leaders with high self-awareness demonstrate humility and appreciation. They are keenly aware of their strengths and weaknesses. How can you achieve high self-awareness? Keep a journal of your thoughts and interactions during the day that includes reactions of others to you. Find a method that will allow you to respond rather than react. Some techniques to encourage responding include counting to 10, excusing yourself for a moment, or asking for a meeting or the opportunity to give an answer at a later time.
Self-regulation requires establishment of acceptable response patterns that include (a) careful and measured non-emotional responses (no cynicism or sarcasm); (b) making measured decisions; never rushed or with an emotional response; (c) universal or neutral approach to all people regardless of status, race, gender, etc.; and (d) never compromising personal, organizational, or professional values. How can you achieve high self-regulation? Leaders must draw the line designating where they can and cannot compromise; to do this, leaders must clarify their values and those of their profession. A good way to do this is to ask yourself what your code of ethics is. Knowing where you stand ethically will support ethical and moral decision making. Another way to achieve self-regulation is through self-accountability. Leaders must be accountable for their actions; stop blaming others, the organization, and the situation. Facing errors, challenges, and barriers earns respect and admiration from others. Lastly, practice calmness. Monitor your behavior the next time you feel yourself becoming anxious. How are you acting? Do you get quiet or do you scream? Practice breathing. This may seem silly, but often we do not take full, even breaths in situations that are difficult; breathing helps to keep you calm. To relieve stress, express it in a manner that is acceptable. An acceptable manner is to write down everything that you would like to say, then file it away, never to be read by anyone but you.
Motivation can come from others or can be created within yourself. The best leaders have high standards and clear goals. These people are focused on achievement. How do you get yourself more motivated? To get more motivated, you need to reexamine what you love about your job. If you are struggling with even one thing, begin with something concrete such as “I love that I get paid for the job I do”; “I love that I receive a great insurance plan”; “I love that I earn vacation time”; and so on. If you are a leader, recall the whys that led you to originally apply for the position. The use of the whys is a valuable technique to reevaluate performance. Completing this process helps to find the issues that are creating problems and discover possible solutions.
Take a look at an example below:
Why am I unhappy?
Because I was reprimanded for missing a deadline.
Card 1 of 5
View each term then click “Flip Card” to see the definition.
Empathy is a critical component in the demonstration of emotional intelligence. Empathy is the quality in which the leader has the ability to see the issue or concern from the other person’s point of view. This component requires leaders to be fair in dealing with all staff, to step up and give positive and negative feedback, and to listen carefully to the concerns of others. Leaders who are empathetic earn respect and gain the loyalty of their staff. How can you learn to be more empathetic? Think of a time when you were in conflict over an issue. Of course, it is easy to justify your point of view, but now reverse the roles (just as you might in a debate class). What are the strengths of the other person’s argument? What makes that argument valid? How might this person’s problem solution effect the needed change? Another strategy to alert the leader to empathy is to attend to the body language of the person that they are engaged with. Is the person crossing his or her arms, indicating that he or she is closed? Is the person failing to make eye contact (remember to consider culture here)? Does the person smile as a negative response is given, indicating incongruence? Lastly, be sure to acknowledge feelings that you observe and hear from others. Some examples include seeing a sad face when you advise a staff member that you will not be able to grant requested vacation time. A leader who sees the sad face should state, “I can see that you are sad that I cannot grant your vacation time.” Allow the person to speak and share his or her feelings.
Social skills are the last of the emotional intelligence components. The best leaders are open to hear the positive and negative and embrace the opportunity to be advised of these types of situations. These leaders are expert managers of change and conflict resolution. Leaders with the best social skills understand that when they are in their organization, or even in the public domain, they are on stage. Everyone looks to the leader to demonstrate appropriate behaviors at all times. The leader sets the tone for all those who are under his or her sphere of influence. For example, if you are the chief nursing officer and you have a bad temper and treat your division directors poorly, then it will be expected that this is appropriate organizational behavior. Thus the division directors will tend to demonstrate bad temper and treat the leaders who report to them poorly, and so on. How can you improve your social skills? Leaders should take advantage of educational experiences that offer interactive opportunities. The topics of these educational experiences should be conflict resolution, communication, and how to give well-deserved praise and rewards to others.
Working toward competency in each of the five areas of emotional intelligence will guide those who wish to be in leadership roles and those who are in leadership roles to perfect their ability to gain respect and loyalty and move staff effortlessly through change (Taft, 2013).
Leader as Change Agent
The majority of a leader’s role is to ensure that staff and patients are satisfied, that quality care is achieved, and that new innovations are adopted that have a positive impact at the unit, the division, and the organization level. The completion of these tasks requires change. The role of the leader is the role of the change agent (Porter-O’Grady & Malloch, 2015).
A leader’s goals should mirror those that have been identified as a standard of excellence, such as the Magnet Recognition program of the American Nurses Credentialing Center (ANCC, 2014), a part of the American Nurses Association. The vision of the Magnet recognition program identifies the delivery of nursing to be based on knowledge and expertise. Magnet recognition is based on core principles and adaptability and aims for continuous innovation and discovery. The model for Magnet recognition consists of five components: (a) transformational leadership practice; (b) organizational empowerment; (c) flawless professional practice; (d) attainment of new knowledge, improvement, and implementation of innovation; and (e) practical outcomes (AACN, 2014). Those attending to the Magnet standard of excellence must also have a broad view that encompasses all organizational levels. In addition to these components, the standard has the overarching expectation that nurses work to the full scope of their practice; have autonomy; are encouraged to make bedside decisions; engage in collaboration related to the work environment; have support for ongoing professional and academic education; and pursue development within their career goals, including leadership and clinical expertise.
Leaders who follow a standard for excellence will be creators of opportunity, use evidence to base all decisions, and have a clear and articulated vision. Leaders will encourage the professionals whom they lead to ask questions and consider taking risks related to interactions with others and proposing alternate care actions. Additionally, these leaders are not found in offices but are among their staff; visible, rounding, communicating, and accessible. Informal leaders can be highly effective in the role of staff champion for these types of changes and support formal leaders to achieve their goals. However, goal achievement related to change requires a carefully guided process to ensure understanding, acceptance, and adoption of the change as a part of new practice and workflow.
Combining the concept of the NSDT and emotional intelligence within the function of leaders sets the stage for dynamic, professionally satisfying work for staff and leaders and provides patients with motivated expert nurses who are proactively engaged in seeking the best practices that align with the needs and desires of the patient. Leadership is the toughest job that nurses will ever love and the most rewarding to see staff develop, patients flourish, and professionalism become the norm. Becoming the leader who can accomplish these many duties with the consistency that is demanded in the organization takes time and practice. Change is the one constant that is at all organizational levels and offers immediate learning opportunities for staff, potential leaders, and current leaders to gain mastery of this dynamic and important process that is a key to success (Porter-O’Grady & Malloch, 2015).
Marquis, B. L. & Huston, C. J. (2014). Leadership roles and management functions in nursing: Theory and application. (8th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
• Chapter 2: Classical Views of Leadership and Management
• Chapter 3: Twenty-first Century Thinking about Leadership and Management
• Chapter 12: Organizational Structure
Battilana, J. & Gasciaro, T. (2013, Jul-Aug). The network secrets of great change agents. Harvard Business Review. link to article
Jayanthi, A. (2013). Using an input-throughput-output model to minimize cost, increase value. Becker’s Control & Clinical Quality [online]. link to article
Johnson, V., Wessel, T., & Johnson, K. (2013). Building collaboration between CNOs and direct-care nurses. American Nurse Today [online], 8(1). link to article
Krueger, D. L. (2013). Informal leaders and cultural change. American Nurse Today [online], 8(8). link to article
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