Leadership Final Exam

• practice as a graduate nurse until you receive the results of your first attempt on the NCLEX-RN, OR
• 3 months after graduation

• Continuing education (in services, equipment changes, current trends ect)
• Professional organizations - Specialty organizations
• Political activism - Stay up to date on health care policy and reform
• Value your work
• Work where you feel empowered

• Constantly taking care of others and giving to others is exhausting
• To take care of others, you must first take care of yourself
• Seeking time off on a regular basis - avoid burnout
• Boundaries between work life and home life
• Do recreational activities

• Nursing is a female dominated profession
• More men are being added to the profession
• Women have not always wanted to have power or to lead (leadership)

• The timing is right
• The size of the nursing profession - 3 million nurses
• Nursing's referent power - nurses are seen by the public as honest and trustworthy
• Increasing knowledge base and education for nurses-More nurses are moving away from bedside to NP, educator, admin, ect
• Nursing's unique perspective - practice with a lot of autonomy, scientific knowledge and research from nurses
• Desire of consumers, politicians, and providers for change - people are ready to see more people become nurses, see them have the resources they need and succeed

• Rising health care costs, declining insurance reimbursement, healthcare initiatives, technology improvements, increasing elderly populations
• Depends on the person or change agent leading the process
• Depends on the human aspect and emotions.

well planned, thought out, deliberate, research and preparation

must have a vision for change

• must be flexible and open to the thoughts of others.
• People tend to not trust outside people, but outside people tend to be more objective. They see pros and cons easier. Inside people have more bias and opinions.

3 steps (unfreezing, movement or change, and refreezing)

• Ensures that employees are ready for change.
• The leader has to place a focus on the need for change, and the catalyst or agent of change needs to remain focused.

Execute the intended change

Ensures that the change becomes permanent.

• show the benefits. Resistance is natural, and it depends on how proactive the agent and leaders are.
• •Identify the source of resistance and allow people to discuss it. This is the time to collaborate.

• Place nurses in positions of influence - nurses on committees and boards
• Promote greater research to strengthen evidence - based practice
• Support nursing leaders, not just physicians
• Mentor future nurses

• nurses that don't want to help other new nurses
• “I clawed my way to the top and you should too”

• Maintain personal energy internally.
• Present a powerful picture to others - be the professional and show your skills
• Work hard, be a team player.
• Determine the powerful in the organization.
• Learn the language and symbols of the organization.
• Learn how to use the organization's priorities.
• Increase professional skills and knowledge
• Maintain a broad vision.
• Be flexible.
• Develop visibility and voice in the organization.
• Learn to accept compliments and 'toot your own horn'.
• Maintain a sense of humor.
• Empower others.

Provides the framework for the authority, the responsibility and accountability. Has an emphasis on positions.

• board of directors
• chief nursing officer
• CEO
• COO

• Day to day operations, long term planning policies.
• •Unit managers
• •nursing supervisors
• •nursing directors

• Immediate daily operations, employee satisfaction, influence productivity
• •charge nurses
• •team leaders
• •case managers
• •primary care nurse

• Natural structure that comes from the informal structure of co-workers
• Social networks of employees. Focuses on employees and their relationships with each other
• Often unplanned and “hidden”
• Grapevine - Heart of the informal organization
• ocommunication heart of the informal organization but it is not always accurate

• Only shows the formal structure, it does not show the informal structure.
• Dynamic - Can become obsolete very quickly
• •Roles change, people change, structure changes, people leave

•duty or assignment

• Leaders are morally responsible for the consequence of your actions
• However each individual is responsible for their actions too.

Max Weber, German Social Scientist- Father of Organizational Theory

• Clear division of labor
• Hierarchy of authority
• Impersonal rules - You can't simply act any way you please
• Procedures - For dealing with work situations, how things are done, eb and flow
• Rights and duties of each position
• Employment and promotion based on technical competence

• they are very dynamic and people are always moving and leaving
• always follow the chain of command
• Should only be breached in the instance of ethical situations
• they don't show any informal structures only the formal structures

• The values and behaviors that contribute to the unique social and psychological environment of an organization
• A sum total of values, language, traditions, formal and informal communication networks, and the rituals of an organization

• How employees perceive an organization.
• Often confused with organizational culture
• Perception may be accurate or inaccurate
• People in the same organization may have different perceptions about the same organization.

• defined as the force within the individual that influences or directs behavior
• Because motivation comes from within a person, managers cannot directly motivate subordinates. The leader can, however, create an environment that maximizes the development of human potential.

• motivation enhanced by the job environment or external rewards
• Engagement, a key to retention, is an employee's emotional commitment to the organization and its goals.

• Have clear expectations for workers.
• Workplace boundaries are important, but be fair and consistent with employees.
• Encourage teamwork.
• Know the uniqueness of each employee.
• Stretch employees intermittently.
• Reward desired behavior.
• Allow employees as much control as possible

Failure to exercise the care toward others that a reasonable person would do in the circumstances, or taking action that a reasonable person would not.

(also called professional negligence)-specialized form of negligence that is only applicable to licensed professionals. An act or continuing conduct of a professional that does not meet the standard of professional competence and results in provable damages to the client/patient.

• Duty to use due care
• Breach of duty
• Foreseeability of harm
• Injury
• Direct relationship between breach and injury

• The care that should be given under the circumstances (what the reasonably prudent nurse would have done) Ex: a nurse should give medications accurately, completely, and on time.
• The testimony of other nurses in the same specialty as the defendant may be used to prove

• failure to use the degree of care required under the circumstances
• not doing anything can lead to this as well Ex: a nurse fails to give medications accurately, completely, or on time.

• a nurse's obligation to have knowledge about the standard of care and understand that failure to meet the standard may result in harm or injury. Ex: The drug handbook specifies that the wrong dosage or route may cause injury.
• Ignorance of the law is not an excuse

Harm or damage. Ex: Convulsion or other serious complications occur.

a relationship between what was done incorrectly and the injury that the patient acquired. Ex: wrong dosage causes a patient to have a convulsion.

Negligence applies to a non-licensed individual while malpractice applies to a licensed individual

the restraint of a person's liberty of movement by another party who lacks the legal authority or justification to do so. This is also categorized as an intentional tort.

• making optimal use of available time.
• Time is an important resource.
• Good time management skills allow an individual to spend time on things that matter.

self-determination; being independent and self-governing, personal liberty, freedom of choice; accepting responsibility for your choice; keep patients informed. (Ex) obtaining informed consent, accepting the situation when pt refuses medications, maintaining confidentiality

duty to do no harm. If you can't do good then do not do harm. Accept the lesser harm to avoid the greater harm. Avoids negligence

doing good; actions taken to promote good; what is best for the patient. (Ex) planning performance appraisals, manager is likely to view them as a means of promoting them

treating people fairly and equally. Equals should be treated equally and unequals should be treated according to their differences

keeping promises and commitments made to others, usually through moral obligation.

Protecting a person’s privacy and information; respecting the rights of others.

Telling the truth; honesty

the rules people develop as a result of cultural values and norms that guide what you consider important and unimportant.

specific ideas that people hold to be true. May not always have factual evidence.

focused on good vs bad - the rules people develop as a result of cultural values and norms (derived from our conscious) (The motive behind a person’s actions)

a systematic study of what a person's conduct and actions should be with regard to self, other human beings and the environment what guides a person's actions on what is right and what is wrong "doing the right things"

key to time management.

• Getting work done through others.
• Synonymous with productivity.
• The RN is still responsible/accountable to make sure the task is completed.
• Benefits include: improved productivity, learning opportunities, job satisfaction

One role of leadership

• People have to follow, don't necessarily want to follow
• Guide, direct, and motivate others
• Intervene when goals are threatened
• Emphasize control
• Involved in day to day work
• Manage and hold accountability for the team
• Go to person when struggles arise
• Praise and address issues
• Must be self disciplined
• Must have a tough skin, can say no, not swayed by emotions

written/printed defamation of character (including social media)

• Protects patients' right to confidentiality-patient has to give permission for records to be shared
• Penalizes for unauthorized release of information

NCSBN oversees?-Oversees all state boards of nursing. Involved in research. Administers licensure tests. Not for profit.

to protect the public

• How nurse practice acts guide nursing practice
• Must include a board of nursing, an administrative court that has the power to make decisions about nurses careers and disciplinary for violations to ensure laws are followed
• Education program standards, standards in scope of nursing practice, defines different types of licensing and requirements and grounds for disciplinary actions for violations and remedies
• Each nurse practice act establishes a board of nursing that has the authority to develop laws and enforces act

statutory law

• Statutes and laws originated to protect the public from unsafe, unlicensed practice by regulating nursing practice and nursing education.
• •Defines nursing as a profession
• •Sets standards
• •Guides practice-provides parameters in which to work.

written laws enacted by legislatures at the state and federal level

• Individual sued by state or government agency
• •Example – State Board of Nursing
• •Punishment - being sued by the state board of nursing, actions against license (including suspension or revoking), drug testing
• •Penalties - probation (can still practice but must meet certain requirements such as drug testing etc), suspension (lose license for a certain time frame), censure (placed on record that crime is committed and warning is placed) revocation (canceling license, losing it forever)

• protects the private and property rights of individuals and businesses. Based on preponderance of evidence; the judge has to believe that it’s more likely than not that the crime took place.
• •Punishment: Typically monetary damages; most malpractice falls under civil cases. Private individuals or groups may bring legal action to court for breach of civil law. (Torts & Contracts)
• •Contracts- one party asserts that the other party, in failing to fulfill an obligation, has breached the contract, and either compensation or performance of the obligation is sought as remedy.

• Provides protection from conduct deemed injurious to the public welfare. Provides for punishment of those found to have engaged in such conduct. (Ex) stealing hospital supplies/drugs
• •Crimes against individual or society
• •Proof of the crime must be beyond a reasonable doubt
• •Innocent until proven guilty
• •Punishment: Incarceration or death
• •Example: intentionally administering fatal doses of drugs to pt

• The nurse's role is to be the WITNESS of the signing of the consent.
• The patient must have had an explanation of the procedure from the provider of the procedure

The patient must be a legal and competent adult that has been educated on risks/benefits by the provider doing the procedure.

• A competent adult
• Legal guardian or DPOA
• Mature minor
• An emancipated (minor declared as adult) or married minor
• Parent of a minor child
• Court order
• Federal law provide exception for consent from a minor in relation to: chemical abuse, pregnancy, and STI

• To inform your leader/manager if you are in a position to not provide competent and quality care to your patients.
• To not abandon your patients, and to treat the shift as if it was any other shift in terms of high quality of work and patient care.

• Many potential employers check social media
• Often people seeking jobs are eliminated due to social media posts
• Social media speaks to who you are: culture, values, beliefs and professionalism

Allows for social and professional networking and potentially can lead to job opportunities if networked correctly and professionally.

• Inappropriate pictures - “No hoohah or tata pictures”
• Complaints about current job
• Posting conflicting information on your resume
• Statuses you wouldn’t want your boss to see
• Not understanding your security settings
• Losing by association - Judgment based on associates. “birds of a feather”

LinkedIn

• Research the hospital
• Arrive 10-15 minutes early
• Smile
• Bring several copies of your resume
• Make eye contact
• Ask 3 questions about the unit

• Be an idiot
• Wear a bikini
• Disclose personal information

earliest phase - first 10 years of nursing - less experienced, experience reality overload

• socialization to the nursing role - becoming an insider, learning
• •building knowledge, skills, and abilities
• gaining exposure to new and different experiences
• identify strengths and weaknesses - can ebb and flow; change
• positioning yourself for the future-certifications, additional education, etc

Nurse and theorist that came up with the levels of nursing experience

when you first go to work; no experience

gaining confidence, know the lay of the land, is socialized

nurse has been in the same environment for 2-3 years

skilled,, or capable in any field or activity

a person with special knowledge or ability who performs skillfully

Middle career phase ~11-29 years of career

• gaining mastery
• finding your voice

• to not stagnate and no longer challenge self or grow any longer
• stagnating is becoming bored
• Committing to life long learner; certifications/education for career divergence.

• Milestone-later career, 30-40 years of experience, prime experience, experts
• Challenge-Avoiding obsolescence, do not become outdated and no longer producing or being used

• Reentry (Not all experience this phase, but more common now)
• not something that everyone is involved in, it is for the nurses who decided to leave the field and then come back, it is a learning curve when you come back because new equipment and medication are introduced and there will be a retraining that occurs

• Reduce employee attrition-justification for career development plans (offer incentives, especially in momentum phase.)
• Equal Employment Opportunity role-minority opportunity for advancement that is not limited to race
• Increased opportunities for employee growth-defined career ladder for growth
• Improved quality of work life- work/life balance
• Improved competitiveness of the organization- pay
• Avoids obsolescence and new skill acquisition-staying career oriented to avoid stagnation
• Promotion of evidenced based practice

• Self assessment-What do I want to do? What is it going to take to get to that goal?
• Evaluate strengths/weaknesses
• Goal setting-make 5 year goals
• Looking for opportunities and preparing-More education/training?

Priority setting, managing and controlling issues, balancing work and personal time

• Explore-How is time currently being spent?
• Goals-Set goals on what you want to achieve (daily, weekly, monthly)
• Prioritize-Need to do's versus want to do's
• Steps-Break down into realistic and manageable steps
• Plan and establish priorities
• Complete the highest priority task first and complete each task before moving on to the next
• Re-prioritize tasks based on time remaining. Return to step one if needed.

• Assess the team
• Gather supplies and equipment in advance
• Cluster activities
• Use time estimates
• Document ASAP (Ex. document in room while talking to patient)
• Take breaks
• End the workday on time
• Delegate as needed (RN still responsible for outcomes and data gathered)

• make lists
• allow time for planning
• create a schedule
• be flexible
• be realistic
• avoid procrastination and distraction
• exercising between study sessions
• re-evaluate your schedule and re-prioritize
• electronic tasks and reminder lists

• Priority setting IS critical!
• Three categories
• oDon’t do “clutter”
• Outdated tasks
• will take care of themselves
• better accomplished by someone else - delegate blood sugar
• oDo now
• Emergencies (ABC’s)
• daily operational needs reports, assessment, med pass
• oDo later
• trivial
• task doesn't have an immediate deadline - iv tube change or dressing change

• Systemic before Local shock before leg injury (bigger more life threatening injuries over local injuries)
• Acute before Chronic (a new injury over a chronic, ongoing injury exacerbation of asthma before COPD, change in Mental health issue vs?)
• Actual problems before potential problems (Pt in pain before ambulating another)
• Listen carefully and don't assume
• Recognize and respond to patient trends vs. transient findings (dropping blood pressure gradually all day long is a trend and a patient's blood pressure that increases during times of pain but drops after pain medication was given)
• Recognize medical emergencies and complications vs. expected findings

• Right task
• Right circumstances
• Right person
• Right direction/communication
• Right level of supervision

• One that is delegatable for a specific patient. Is this within scope of practice? Is the task delegatable?
• Can't delegate "TAPE"

Appropriate time, patient setting, available resources, and other relevant factors considered. Consider the workload of the delegate. Nurses should not delegate unstable patients. Don't delegate documentation during a code to a noob.

Right person is delegating the right task to the right person to be performed. Is it within their scope of practice? Are they certified/competent in the task? Is the person good/comfortable with the task?

THIS IS KEY. Clear, concise instructions for the task including its objective, limits, expectation, and time frame

Appropriate training, explanation, and monitoring, evaluation, intervention as needed. Feedback is given and it is ensured that the task is done correctly. Accountability cannot be transferred. Trust is important.

• •Teaching
• •Assessing
• •Planning
• •Evaluation

• •Modeling the way-Knowing your values, self awareness, not wavering
• •Inspiring a shared vision-making others believe they can make a difference
• •Challenging the process-"Why are we doing it this way?"
• •Enabling others to act-fosters and encourages trust and collaboration
• •Encouraging the heart-celebrate the accomplishments of their followers and the team (it's not just about them)

• strict structure, leader makes decisions (High productivity, low morale)
• ‘I’ statements with an authoritarian leader - “I want you to do…”
• Strong control is maintained over the work group

• group decisions, slowest results but “most fair” (High morale, low productivity)
• Seeks input from followers, and may include
• employees in decision making
• ‘We’ statements “Look at what we accomplished…”

• completely permissive and hands off approach, as long as work gets done.
• Emphasis is on ‘you’ – ‘you get the job done’...“It’s up to you…”
• must be working with a highly motivated group

• Multicratic or Participative Leader: compromise between autocratic and. democratic leader.
• Processes feedback from the group but makes. all decisions.

surround themselves with others that have strengths in areas where they are weak to create a balanced team of these

• 1. Strategic Thinking – focus on a long-term future (5yr/10yr)
• 2. Influence – can sell ideas, develop political support & can rally supporters
• 3. Relationship Building – can unite a group into a team to work toward a common goal
• 4. Execution – gets things done by translating plans into action

Trust, Compassion, Stability, Hope

• Intelligence
• Initiative
• Emotional maturity
• Communication skills
• Consensus building ability
• Ability to recognize allies and opponents
• Social skills and the desire to participate in social activities
• Problem solving/critical thinking
• Self-confidence
• Adaptability

• Leaders must adapt their leadership style according to the situation they find themselves in, and must consider the needs and abilities of their subordinates, among other factors.
• Can be based on maturity of group and with who all is involved

Leadership behavior is generally determined by the relationship between the leader's personality and the specific situation

• the leader, the Forward thinker (CEO)
• Identifies common values/goals
• Is a caretaker by working with their staff
• Inspires others with vision-Has long-term vision
• Looks at effects more than causes
• Empowers others
• Leaders and the followers keep each other accountable, “raise” each other up.
• engage and create connection to raise level of motivation and morality for all - attentive - help follower reach maximum potential, common values, a caretaker, looks at cause and effect, empowers others, unlocks what is and what can be

• day to day actions
• “Traditional leader” - Focuses on management tasks
• Is directive and results oriented
• Uses trade-offs to meet goals
• Does not identify shared values with followers
• Examines causes, not effects
• Managers focuses on causes, where leaders focus on effects
• Uses contingency reward (pizza parties if you meet goals)
• traditional day to day operational leader

• These are the practices that an exemplary leader demonstrates
• 1. Modeling the way - Knowing your values, self awareness, not wavering
• 2. Inspiring a shared vision
• 3. Challenging the process- “Why are we doing it this way”
• 4. Enabling others to act - Fosters and encourages trust and collaboration
• 5. Encouraging the heart - celebrate the accomplishments of their followers and the team (it’s not just all about them)

• Can use all management styles & keeps it in their “tool box”
• A model that depicts 3 management styles on a continuum: laissez-faire, transformational, and transactional management

• 1. Inspirational motivation, Transformational
• 2. Idealized influence (attributed), Transformational
• 3. Idealized influence (behavioral), Transformational
• 4. Intellectual stimulation, Transformational
• 5. Individualized consideration, Transformational
• 6. Contingent reward, Transactional
• 7. Activate management-by-exception, Transactional
• 8. Management by-exception passive, Transactional
• 9. Non Leadership , Laissez faire

• Nursing had to change d/t improving technology & growing elderly population
• Becoming more community based nursing rather than just acute care setting
• Nursing profession had to change to be able to keep up
• Newer generations are expecting different things than what older generations expected
• Positive work environment, more hands on leaderships
• “Top → down” method of leadership is not working anymore

surround themselves with others that have strengths in areas where they are weak to create a balanced team of these

• 1. Strategic Thinking – focus on a long-term future (5yr/10yr)
• 2. Influence – can sell ideas, develop political support & can rally supporters
• 3. Relationship Building – can unite a group into a team to work toward a common goal
• 4. Execution – gets things done by translating plans into action

• Level 1- Highly Capable Individual
• Level 2 - Contributing Team Member
• Level 3 - Competent Manager- Can do day to day operations as well as their management duties
• Level 4 - Effective Leader
• Level 5 - Great Leader- Remains humble and knows when to ask for help (you don't know everything)

• focuses on increased service to others rather than to oneself
• Fails if anyone in the system does not do their part
• Managers effectively give staff what they need to be able to serve their patients effectively

• Principal is the organization, agents are the employees/follower
• Analyses of how policy makers (principals) can control actors who work for them (agents) but have far more information
• agent makes decisions on behalf of the principle
• principles must motivate the agents with incentives to do what is in the best interest of the organization

• Human capital represents the capability of the individual(the employee)
• Social capital represents what a group can accomplish together.

• Refers to use of emotions effectively
• Be open minded and look at things from different points of views
• Empathetic
• Critical for cooperative team

• 1. Self awareness,
• 2. self regulation (control/redirect/don't be reactive)
• 3. motivation(passion for work beyond money)
• 4. show empathy
• 5. good social skills

• the view that effective leaders need to be aware of, feel comfortable with, and act consistently with their values, personality, and self-concept
• it takes courage to not bend to the will of others and they have that courage
• Having integrity and being true to oneself in all aspects of life.

• applies to a person who is recognized among peers for innovative ideas and who demonstrates the confidence to promote these ideas
• Happens a lot in nursing

Rebels are people who break rules that should be broken. They break rules that hold them and others back, and their way of rule breaking is constructive rather than destructive. It creates positive change… Rebel leadership involves positive deviance.

• Think in many ways
• Fast, flexible, and adaptable decision making
• Openness to ideas and innovation
• Inclusive and democratic approach to followers

• Nurse-managers need to continually adapt, reflect on progress and setbacks, and adjust their course.
• Consider what one knows
• Believe and value current situation
• Reframe to develop future respons by es and actions

• leadership that moves beyond the traditional modes previously experienced by all levels of workers; spawned by the impact of the information age on work and the worker
• leaders work with employees to fulfill/identify common goals
• exploiting opportunities
• empowers staff to be more productive

Quality Improvement-it is used to target and continually improve quality in healthcare.

includes defamation of character with slander or libel, invasion of privacy, breach of confidentiality, breaking HIPPA

Let employees know the level of their job performance as well as any expectation that the organization may have of them. They generate information for salary adjustments, promotions, transfers, disciplinary actions and terminations.

It's a natural response because change disrupts the homeostasis of the group. The level of resistance depends on whether or not the change is mandated or proactive. Proactive change is usually less emotional than mandated change. The degree of resistance depends on the type of change (Ex. social vs technology), subordinates' values, education levels, cultural/social background, and experience with change (positive or negative).

• A common response to delegation is “no not doing that”
• see things from the other person's perspective and understand their workload and responsibilities and rather or not they can handle an additional task delegated to them
• Believe they are incapable of completing the task - maybe they have never done this task before.
• oApproach → guidance & coaching - Is the task appropriately delegated?
• Resistant to authority – “test the water”
• oApproach → calm, but assertive
• oNeed to work as a collaborative team, the task still needs to get done
• Overdelegated in terms of “specificity”
• oApproach → allow independent thinking & creativity coupled with constructive feedback

• Ensures that employees are ready for change.
• The leader has to place a focus on the need for change, and the catalyst or agent of change needs to remain focused.

Execute the intended change

Ensures that the change becomes permanent.

• Expect resistance! - show the benefits. Resistance is natural, and it depends on how proactive the agent and leaders are.
• Identify the source of resistance and allow people to discuss it. This is the time to collaborate.
• Resistance is a form of competing (such as in conflict resolution)
• In delegation - see things from the other person's perspective and understand their workload and responsibilities and rather or not they can handle an additional task delegated to them

• the patient's medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions.
• Focus on safety and key assessments/information such as recent labs that indicate the patient is now anemic

• If you don’t rules, there can be no progress.
• Negotiation resembles compromise, each party gives something up and the differences are looked at and are accommodated
• Goal- the other party feels satisfied with the outcome

preparing, gathering information, know how much you are willing to compromise and what you are willing to accept

• negotiator should be calm, collected, and self-assured
• If emotions get high; step away and take a break
• Be prepared for destructive negotiation tactics- manipulation, inappropriate questioning, intimidation, flattery, sadness, aggression (stay calm, step away if it make you emotional)

• completion of the conflict process
• can be negative or positive.
• oPositive - Fair outcome, everyone leaves the situation happy
• oNegative - Issues remain. The aftermath of conflict may be more significant than the original conflict if the conflict has not been handled constructively.

• affected by cultural diversity in the workplace- dialect, volume and eye contact, use of touch, context of speech, kinesics (gestures, stance, and eye movement) all influence how messages are sent and received.
• oEx: Delegation delivered in a softer tone may be perceived as less important than delegation received in a louder tone.

Influencing delegation-distance and intimacy techniques; recognize the personal space needs of each staff member

importance of a group or unit in providing social support in a person’s life.

• Some culture groups can be more past, present and future oriented.
• (Ex. Greek/Italian cultures doing things at their own pace and never on time.)
• Past: preserving the past and maintaining tradition
• Present: Maintaining the status quo and on daily operations
• Future: goals to be achieved and are more visionary in their approach to problems

• Person's perception of control over his or her environment-
• Ex. don't give discharge instructions while the family is halfway out the door trying to leave
• believe in fate, luck or chance - may affect how people approach a task

The final phenomenon --biopsychosocial differences between racial and ethnic groups as well as gender; susceptibility to disease and physiologic differences

• recognition program (not award) for excellence in healthcare. It is given to hospitals that achieve certain goals such as:
• Attracting and retaining nurses with excellent performance
• Higher adoption of National Quality Forum safe practices
• Higher support for implementation of evidence based practices
• Higher nurse-perceived quality of care
• Higher patient ratings of the hospital experience
• Lower mortality rates
• Lower failure to rescue rates
• Lower patient fall rates
• Lower nosocomial infections/pressure ulcers/CLABSIs

program established in 2003 that health care organizations and long term care institutions for positive practice environments where nurses excel. It recognizes supportive practice environments, including an established shared governance structure that values nurses' contributions in every day decisions, especially those that affect their classical practice and well being.

• (Internal/Inside)
• Defined as the force within the individual that influences or directs behavior
• Because motivation comes from within a person, managers cannot directly motivate subordinates. The leader can, however, create an environment that maximizes the development of human potential.

• (External/outside)
• Motivation enhanced by the job environment or external rewards
• Engagement, a key to retention, is an employee's emotional commitment to the organization and its goals.

• Scope of responsibility-Look at organization as a whole as well as external influences
• Primary planning focus-Strategic planning
• Communication flow-More often top-down but receives subordinate feedback both directly and via middle-level managers
• Examples: Board of Directors, Chief Executive Officer, Chief Nursing Officer, Administrators

• Scope of responsibility-Focus is on integrating unit-level day-to-day needs with organizational needs
• Primary planning focus-Combination of long and short range planning
• Communication flow-Upward and downward with great centrality
• Examples-Nursing Supervisors, Nursing Directors, Department Heads

• Scope of responsibility-Focus primarily on day to day needs at unit level
• Primary planning focus-Short-range, operational planning
• Communication flow-More often upward; generally relies on middle-level managers to transmit communication to top-level managers
• Examples- Team leaders, Charge nurses, Primary Care nurses, Case Managers