Chapter 4
A number of decision-making strategies have been identified for clinical and
managerial decision making. An effective strategy for nurse managers to select in
examining possible causes related to delivery of services would be:
A) Fish Bone Charts
B) Cost-Benefit Analysis
C) Pilot Project
D) scenario planning
Answer- A - Fish Bone Charts
This strategy helps
identify processes, materials, equipment, role responsibilities, or environment as
potential causes for the clinical or management effect. Pilot projects are limited
experimental trials used to develop an optimal and alternative solution to a
problem. Cost-benefit analysis is an appropriate strategy to use when deciding
budgetary issues and may include listing the positive and negative aspects of a
given outcome to assist with decision making. Scenario planning is used in a
group setting to brainstorm about the future and is a beneficial strategy to use in
a constantly changing environment.
All nurses must know how to be effective team players, which includes a variety of skills such as technical and functional expertise, problem-solving and decision-making skills, and interpersonal skills. Which of the following statements best reflects this?
A) Nursing staff members must be able to function interdependently with others.
B) Members need skills to give input, participate in decision making, share responsibility, and hold the manager accountable for the outcomes of the group.
C) The formation of a well-functioning group or team is often the work of the leader.
D) Leaders and managers must be able to function both independently and interdependently with others.
Answer- D
The correct answer is leaders and managers must be able to function both independently and interdependently with others. This statement applies to all nurses as well. The formation of a well-functioning group or team is never the work of just the leader. Staff members must be able to function independently as well as function interdependently with others. Members need skills to give input, participate in decision making, share responsibility, and hold themselves, not the manager accountable for the outcomes of the group.
A deliberate and cognitive process of becoming responsive and sensitive to the client’s culture, values, and learning to avoid imposing on them is:
A) cultural awareness
B) cultural skill
C) cultural knowledge
D) cultural diversity
Answer- A
Cultural awareness is the first step in the process of realizing that cultural mismatches exist and being open to respond proactively to others who have unique values, beliefs, and cultures. Cultural knowledge is a process of seeking and obtaining an educational background about the different world views of various cultures. Cultural diversity is not a process but rather the variety and differences in the customs and practices of defined social groups. Cultural skill is a process of learning how to do a cultural assessment, allowing the nurse to identify an individual client’s perceptions, beliefs, and practices.
Demand management focuses on:
A) creating predictable and cost-effective staffing according to real-time patient information based on individual patients moving through their stay as quickly as possible.
B) measuring, predicting, and understanding demand for services, and deploying resources and management to meet consumers’ wants and needs.
C) automating staffing plans in order to staff according to average forecasted care levels.
D) supplying adequacy of product and services to meet client demands.
Answer- B
Demand management is measuring, predicting, and understanding demand for services, and deploying resources and management to meet consumers’ want sand needs. Automating staffing plans in order to staff according to average forecasted care levels is how most staffing processes are set up, but this leads to stress when there is a rapid increase in client admission. It also leads to clinical stress due to the variability of severity of clients among the average or when other responsibilities are competing with the staff’s time, such as discharges, admissions, transfers, or meetings. Automation can provide an alert for open shifts to staff that are available staff. This automation assists in staffing open shifts needed in ambulatory and home settings and not just hospitals. Creating predictable and cost-effective staffing according to real-time patient information based on individual patients moving through would be supported, though the dependency exists to measure, which is not stated in this answer. Supplying adequate product and services to meet client demands is a very broad description to explain the measurement necessary for staffing. Overall, demand management finds ways to control for the variability to address the increases and decreases by better planning, using data about scheduled events such as elective procedures, integration to patient flow and bed management systems, better control over bed assignments based on current unit workload, and improved planning for discharges using shorter shifts.
Which of the following statements is true about problem solving?
A) The team problem-solving method is a slow process and is a poor method for
making decisions.
B) Problem solving is a high-level skill used primarily by health care professionals.
C) Problem solving is a rational and logical thought process.
D) Critical thinking and problem solving are the foundation of effective decision
making.
Answer- C
The correct answer is that problem solving is a rational and logical thought
process. The statement that problem solving is a high-level skill used only by
health care professionals is incorrect, because the high-level skill nurses and
others use is critical thinking, a cognitive skill. The second statement is incorrect
and should state that critical thinking and effective decision making are the
foundation of effective problem solving. Health professionals improve the
effectiveness by using the skill of critical thinking. The third statement is incorrect
because team problem solving is a faster process for making decisions, because
the use of interdisciplinary members of the team enhances the timeliness of a
decision that is made in a silo.
When the group decision-making procedure is that the entire group decides, whether by a two-thirds vote, simple majority, consensus, or some other process, this is known as:
A) consultative decision procedure
B) autocratic decision procedure
C) joint decision making
D) delegated decision procedure
Answer- C
The correct answer is joint decision making, where the entire group decides by simple majority, consensus, or a quorum. The delegated decision procedure is when the leader allows participants to make the final decision. The autocratic decision procedure is when the leader controls the power, and the committee exists mainly for the sake of appearance. A consultative decision procedure is when decisions involve employee participation, but the leader still makes the final decision alone.
Diversity assists with team effectiveness, improves retention of the best people, capitalizes on out-of-the-box thinking, lays the groundwork for future business growth, and provides more supportive work environments. Which of these are benefits to the nursing workforce?
A) Each generation possesses unique characteristics, and often the values and behaviors of an older cohort of nurses help younger colleagues.
B) Communication style, work style, organizational role/level, economic status, and geographic origin are uniform factors helping team effectiveness among nurses.
C) A diverse workplace allows synergy of diverse viewpoints to improve nursing’s knowledge base and care strategies.
D) In the health care setting, diversity among employees helps the awareness of diverse patient and family values, beliefs, and practices.
Answer- C
A diverse workplace allows synergy of diverse viewpoints to improve nursing’s knowledge base and care strategies. The benefits are improved patient data collection, increased preventative care, reduced care disparities from better evidence-based practices, increased cost savings from reduced errors with the right frequency of treatments, and reduced missed visits to family nurse practitioners. The other answers have merit but do not directly impact nursing workforce. Each generation possesses unique characteristics and often deems the values and behaviors of another cohort as character flaws instead of cultural differences. Communication style, work style, organizational role/level, economic status, and geographic origin are aspects of nursing workforce diversity and are not uniform styles within nursing, and the different styles allow nurses to capitalize on out-of-the-box thinking. All health care employees need training on cultural diversity to help with diverse patient and family values, beliefs, and cultural practices.
Scheduling by predictive modeling forecasts unplanned patient and staff events, such as admissions by day of week and unplanned sick calls. Principles supporting such a scheduling process for demand management would include:
A)supporting administration, human resources, and finance to determine the quantity and skill of staff.
B) projecting near future optimal staffing decisions while leaving choices open for available caregivers.
C) scheduling and daily staffing by a patient classification system, with available staff within the EHR for each clinical unit or department, allowing staffing for procedures and tests.
D) embedding a decision support system that receives continuously measured progress on patient outcomes in real time, throughout a patient’s stay, with which actual progress may be compared on individual patient changes in the outcomes-driven acuity system.
Answer- D
Embedding a decision support system that receives continuously measured progress on patient outcomes in real time, throughout a patient’s stay, with which actual progress may be compared on individual patient changes in the outcomes-driven acuity system to make decisions. This answer associates with the principles for effective demand management. Scheduling and daily staffing by a patient classification system, with available staff within the EHR for each clinical unit or department, allowing staffing for procedures and tests, are possible through available technologies, but they do not support demand management principles. Supporting administration, human resources, and finance to determine quantity and skill of staff, while important, does not address the principle of capturing real-time data to support scheduling and staffing. Projecting near future optimal staffing decisions while leaving choices open for available caregivers would be possible using demand management, but the answer does not include any of the principles for an outcomes-driven acuity system based on established well-defined taxonomy documenting patient care and outcomes from assessments. The principle of demand management is to incorporate all present and planned electronic available data to reduce time in data gathering while using real-time valid data on clients. Predictive modeling can forecast unplanned patient and staff events such as admissions by day of week and unplanned sickcalls as well as using electronic health record available data to reduce nursing time in data gathering and provide real-time, valid data.
Any decision in a chaotic health care delivery environment may cause an
unanticipated future problem. Identify the true statement about decision making.
A) Decision making must be even more deliberative when problems require urgent
action.
B) Decision-making strategies are interchangeable and can be used effectively in
any situation.
C) Decision making is not a behavior but rather a method in selecting and
implementing a course of action from alternative courses of action for dealing
with a situation or problem.
D) Decision making is used to solve problems.
Answer- D
The correct statement is that decision making is used to solve problems. The
statement decision-making strategies are interchangeable and can be used
effectively in any situation is incorrect because, for example, ethical decision
making uses ethical principles and moral reasoning in its steps for specific
situations and is not useful when clinical expert decision-making activities are
necessary, which require creative and innovative ideas, adaptation to
uncertainty, understanding of the context of the current problem, and learning
obtained from prior experience. The statement decision making must be even
more deliberative when problems require urgent action is incorrect, because
urgent action requires a rapid decision-making process and with more
information could require a long-term solution. The last statement is incorrect,
because decision making is a behavior exhibited in selecting and implementing a
course of action from alternative courses of action for dealing with a situation or
problem. It may or may not be the result of an immediate problem.
In nursing, group process theory relates to how to work as an employee within an organization that is often large and complex. Which statement best reflects the need for teams and groups?
A) In all groups, decision making is a joint process, with all members participating
B) Group decision making is cost-effective in all situations
C) Interdisciplinary work teams are necessary for complex situations
D) The major reason for individuals to join groups is to gain information.
Answer - C
Interdisciplinary work teams are necessary for complex situations. The high-performance teams create an organization’s efficiency and effectiveness because the collaborative knowledge of the team achieves high-quality work outcomes and controls costs. The second answer is not a reason for individuals to join groups, rather two reasons were identified: (1)to provide a personal or professional socialization and exchange forum, and (2) to provide a mechanism for interdependent work accomplishment. The third answer is about the joint process of decision making, but not all members may participate in a group decision, which typically results in individuals being more committed to a decision, even if there is disagreement. Group decision making is not cost-effective in all situations. It is if it saves time. As new members join the team, it is important to share team members’ expectations. It is also beneficial to revisit the defined expectations on a regular basis.
Management must understand and address aspects of generational workforce diversity. Which of the following statements best describes aspects of the generations?
A) Nexters matured in a world with manipulation of people and limited ethical code to reign. X’ers found the need to be resourceful at an older age. Boomers thrived with efficiency, teamwork, quality, and service. The Silent Generation prefers limited government.
B) Nexters are shallow on advanced skills because technology takes care of every step. X’ers share with boomers the need to push authority aside. Boomers blur gender roles and attempt to push systems toward their conveniences. The Silent Generation likes individualism.
C) Nexters are problem solvers who grew up in a flourishing economy. X’ers desire traditional practices and beliefs. Boomers prefer a participative and more authoritarian workplace. The Silent Generation respects authority.
D) Nexters can create solutions that other generations could not have imagined. X’ers prefer a balanced life and protect themselves from the capriciousness of business challenges, constraints, and rules. Boomers ignore or break rules and will still be successful. The Silent Generation treasures and exhibits conformity.
Answer- D
Managers need to understand that Nexters can create solutions that other generations could not have imagined; X’ers prefer a balanced life and protect themselves from the capriciousness of business challenges, constraints, and rules; Boomers ignore or break rules and will still be successful; and the Silent Generation treasures and exhibits conformity. The first answer is incorrect because X’ers found the need to be resourceful at an early age, and the Silent Generation respects authority and governmental leaders. The second answer is incorrect because Nexters are shallow on basic skills and use technology to guide their every move, and boomers blur gender roles and make vigorous attempts to push systems toward their ideas of perfection. The fourth answer is incorrect because X’ers are skeptical of traditional practices and beliefs, and boomers prefer a participative and less authoritarian workplace.
Staffing management is one of the most critical, highly complex, and time-consuming activities for nurse leaders at every level of the health care organization today. Which of the following statements is correct?
A) Staffing is the implementation of a staffing pattern that indicates the number and type of workers to be scheduled per shift.
B) Variable staffing is based on a set maximum workload requirement.
C) Staffing decisions are based solely on an individual’s philosophy.
D) The staffing management plan is a structured approach to the process of identifying and allocating unit-based personnel resources to optimize care needs, quality outcomes, and effectiveness.
Answer- D
The major goal of staffing management is to provide the right number of nursing staff with the right qualifications to deliver safe, high-quality, and cost-effective nursing care to a group of patients and their families, as evidenced by positive clinical outcomes, satisfaction with care, and progression across the care continuum. A staffing management plan is a structured approach to the process of identifying and allocating unit-based personnel resources to optimize care needs, quality outcomes, and effectiveness. A staffing pattern does not indicate the number and type of workers to be scheduled per shift but rather the number of paid hours per full-time equivalent with skill level and the percent of productive hours in direct care to total paid hours. Variable staffing is not based on a set maximum workload requirements but rather below maximum workload conditions, and staff is then supplemented when needed. Staffing decisions are not based solely on an individual’s philosophy but more often the average forecasted care levels and more recently the near future (2 to 4 days), with an assessment and analysis of staffing needs to ensure competent staff are more available for clients.
What habits are characteristics of critical thinking by nurses? Select all that Apply
A)Experience, uses database resources and searches
B) Quick, concine, purposeful, systematic, within a frame of reference, grounded in
information
C) Open-mindedness, perseverance
D) Confidence, creativity, flexibility
E) Questioning, reflection, contextual perspective
Answers- C, D, E
Open-mindedness, perseverance
It has been noted that habits of the mind that are characteristics of critical
thinking by nurses include confidence, contextual perspective, creativity,
flexibility, inquisitiveness, intellectual integrity, open-mindedness, perseverance,
and reflection. The Critical Thinking Community characterized for a broader
population that critical thinking has a purpose, is systematic, considers
alternative viewpoints, occurs within a frame of reference, and is grounded in
information. It has also been stated that reflection was key to refining one’s
clinical judgment capabilities. Furthermore, clinical experience helps one to refine
clinical judgments. As a nurse gets more experience, the intuitive component of
judgment allows the nurse to grasp the cues more quickly. The last two
statements include items that are incorrect because the thinking is not quick and
concise and does not always involve databases searches.
Team dynamics will need to be addressed to form an effective team. Select the best strategy to help address the challenges in forming effective teamwork.
A) Set group norms on how team members treat each other, how support is demonstrated, how conflict is handled, and the decision-making process to help team members operate with disruptive behaviors.
B) Lead group members through “just in time” training to work together to overcome lack of trust and commitment to the team.
C) Organize appropriate representation and delegation of authority to the group to help team members avoid confusion about the team’s work, accountability, and inattention to results.
D) Keep the number of members in groups between 10 and 14, build a structural team, and coach the team to avoid conflict.
Answer- A
The best strategy is having the group set group norms on how team members treat each other, how support is demonstrated, how conflict is handled, and the decision-making process to help team members operate with disruptive behaviors. The second statement was not suggested as a strategy, though steps to teach team-building skills would overcome the lack of trust and improve the group’s commitment. The third and fourth statements were not suggested strategies to overcome the challenges with team dynamics related to confusion about the team’s work, accountability, and team conflicts. Trust and communication are critical elements of building effective work teams that demonstrate commitment, accountability, and attention to results.
Placing someone from a high-context workplace culture into a setting dominated by leaders from a low-context culture will increase the likelihood of perceptions of inequity and workplace conflicts. What are the differences between low-context and high-context cultures? Select the two statements that are correct. (Select all that apply.)
A) The cultural context of the non-Western world that which is low context does not use the written or verbal message as meaning but has an expectation for those in authority to guide the meaning and direct the decision, which the high-context culture use the written and verbal message as having adequate meaning to allow the communication to direct the decision using rules to guide the understanding.
B) The cultural context of the Western world is low context, and in low-context cultures the explicit verbal or written message carries the meaning, while in high-context cultures, most of the meaning is assumed to exist by the nature of the situation that is the context.
C) In high-context cultures, often found in the non-Western world, that which is written or stated rarely carries the meaning, because the meaning of the message is understood by reading between the lines for what is not written or stated, whereas the low-context cultures in the Western world require extensive detailed explanations and information because they are making up for what is missing in a situation or the context.
D) The cultural context of the Western world is low context, and in low-context cultures the meaning is assumed to exist by the nature of the situation that is the context, while in high-context cultures most of the explicit verbal or written message carries the meaning.
E) In high-context cultures, often found in the Western world, that which is written or stated rarely carries the meaning, because the meaning of the message is understood by reading between the lines for what is not written or stated, whereas low-context cultures require extensive detailed explanations and information because they are making up for what is missing in a situation.
Answers- B, C
B and C answers are correct because in high-context cultures, often found in the Eastern world, that which is written or stated rarely carries the full meaning, because the meaning of the message is understood by reading between the lines for what is not written or stated, as in gestures and practices, whereas low-context cultures in the Western world require extensive detailed explanations and information because they are making up for what is missing in a situation. The cultural context of the Western world is low context, and in low-context cultures the explicit verbal or written message carries the meaning, whereas in high-context cultures, most of the meaning is assumed to exist by the nature of the situation (i.e., the context) or what is customary to the cultural practices, such as in Japan, where there are three levels of bowing which express the meaning of respect or sorrow for actions. Some people develop communication styles based on socially influenced ideas about the value of maintaining relationships. In these relationships they transfer information by means of shared understandings and context to preserve harmony and save face. These high-context cultures influence communication orientation and there is a reluctance to speak up at work. Health care context is always dynamic with both high-context and low-context cultures. The context dictates how information or knowledge is communicated in human transactions or relationships. The Western world is low context and uses explicit verbal or written messages (SBAR) to carry the meaning of a patient situation and requires extensive detailed explanations, information, and contracts how nurses share information with physicians in a given situation. Rules are very clear and followed precisely to get to the outcome. Whereas in high-context cultures as seen in Asia, South America, Africa, and most of the Middle East, verbal communication is less explicit meaning what is written or stated rarely carries the meaning. The meaning is assumed by the nature of the situation and is primarily through personal, face-to-face communication around a central authoritative figure. The rules tend to be more of a suggestion than an absolute dictum. Someone transitioning from high-context workplace culture into one of low-context culture increases the likelihood of perceptions of inequality and workplace conflict.
Which of the following are efforts to measure nursing workload?
A) Segregating patients into acuity classifications allows the staffing pattern to be developed based on the resource requirements of the specific mix of patients forecasted for the unit.
B) Components in determining the severity of illness include a client’s perceived dependency, complexity, task determination, and number of workers available.
C) Acuity is the severity of a client illness and is an automated patient assessment. Information is entered into the patient electronic health record (EHR) by nurses to generate an accurate measurement of patient acuity.
D) The number of client days and the intensity and hours of nursing care required per client day.
Answer- D
The number of client days and the intensity and hours of nursing care required per client day is correct, because the volume of nurses with a certain skill level is needed for a given volume of patients, and the given intensity of nursing care required is related to reduced length of stay, higher patient turnover that requires intensive periods of higher resources for patient admissions, transfer, discharge, and other 1:1 activities for expected unstable patient cases. The patient care plus non-patient care activities include the time, complexity of skill mix, patient dependency, and severity of illness of the work a nurse performs in a given period of time. The second statement is incorrect and relates to severity of a client illness, which can be best determined by automated patient assessment information entered into the patient EHR by nurses to generate accurate measurements of patient acuity. The components in determining the severity of illness are related to the patient and his or her disease and treatment services, not a client’s perceived dependency, the complexity of the condition, or the workers available. The fourth statement is incorrect because it is related to segregating patients into acuity classifications, which allows the staffing pattern to be developed based on the resource requirements of the specific mix of patients forecasted for the unit. That is not workload and nursing intensity.
Select the statement that describes how clinical decision making differs from managerial decision making.
A) Professional nurses in clinical practice are making clinical decisions about client diagnoses and care plan orders, whereas technical nurses are making managerial decisions about containment of costs and maximizing health care delivery.
B) Clinical decision making involves the collection of information, selection, and evaluation of an action, whereas managerial decision making involves the processing of existing information to select an action.
C) Clinical decision making focuses on diagnosing client health issues, risks, or problems and planning or coordinating nursing interventions, whereas managerial decision making focuses on resolution of organizational problems and the plans to achieve organizational goals.
D) Clinical decision making by nurses is far less sophisticated than managerial decision making by nursing executives, nurse managers, and directors.
Answer- C
Clinical decision making focuses on diagnosing client health issues, risks, or problems and planning or coordinating nursing interventions, but managerial decision making focuses on resolution of organizational problems and the plans to achieve organizational goals is the correct statement. The first statement is incorrect: Professional nurses in clinical practice are making clinical decisions about client diagnoses and care plan orders, and the nurse executives and nurse managers are making managerial decisions about containment of costs and maximizing health care delivery. Technical nurses more often lack the formal management and/or leadership education for managerial decisions. The second statement is incorrect because both forms of clinical and managerial decision making involve the collection and processing of information and the selection and evaluation of an action; the focus of the decisions differs. The third statement is incorrect, because the sophistication of clinical decision making differentiates the professional nurse from the technical nurse and can be more challenging than managerial decisions, though the scope of coverage will vary between the two decisions.
Disadvantages of group decision making over individual decision making would include: (Select all that apply.)
A) timely tracking of outcomes
B) disruptive conflicts
C) individual domination
D) premature decisions
E) delayed decisions
Answer- B, C, D
The answer includes premature decisions, individual domination, and disruptive conflicts. The premature decisions lead to the minority view being pressured to accept the majority decision and acceptance of a less than evidence-based decision. The individual domination can become costly and time-consuming for a group’s productivity, because the interpersonal dynamics slow progress and cause an unpleasant experience. The disruptive conflicts can occur over personality differences, differences of opinion, or clashes of values, and these conflicts can become destructive. Individual decision making is without delay and allows timely tracking of outcomes. As a caregiver, the nurse serves a key role as a patient advocate and frequently serves as the coordinator of care with other members of the team. The nurse tracks whether different interventions have been effective. As a care provider spending significant time with the patient, often a nurse will see fine, distinct changes in a patient’s condition before other members of the health care team. Nurses oversee the plan of care in home health, long-term care, hospice, and many other settings.
Cultural differences are characteristics that define individuals beyond unique numbers and names. Which statement is true?
A) Cultural differences do not include eye contact norms, gender issues, touching and physical contact, and food practices.
B)Each generation possesses unique characteristics that are associated with race and ethnicity values, behaviors, and practices.
C) Cultural differences do not generally impact communication, so standard safety and quality of care practices can be sustained.
D) Cultural differences in ways of doing things and in beliefs about health and illness are learned and transmitted via cultural environments.
Answer- D
Cultural differences are the ways of doing things, and beliefs about health and illness are learned and transmitted via cultural environments. Each generation possesses unique characteristics that are not associated with race and ethnicity values, behaviors, and practices, which are also characteristics of diversity. Cultural differences do include eye contact norms, gender issues, touching and physical contact, and food practices. Cultural differences do impact communication, which can change the safety and quality of care through misunderstandings, meanings of words and gestures, and missing context due to translation.
Healthier work environments are associated with better staffing, lower burnout, lower turnover, and improved nurse-physician collaboration. Nurse managers likely should support which of the following statements? (Select all that apply.)
A) There is no correlation between the number of registered nurses (RNs) per client and positive client outcomes.
B) RN-MD collaboration, highly trained nurses, and improving clinical work-flow processes are not always associated with higher-quality patient care.
C) Unlicensed assistive personnel (UAP) assist nurses to perform client care tasks, including vital signs and assessments.
D) Health care agencies that obtain Magnet status often have improved nurse satisfaction, decreased nurse burnout, and better client outcomes.
E) An astute nurse manager can match the skill sets and experience with the patient care needs to deliver the best possible care for clients.
Answer- D, E
An astute nurse manager who knows the staff characteristics in terms of education, licensure, skills, competencies, and experience level can match the skill sets and experience with the patient care needs when making assignments, which will deliver the best possible care for clients. Health care agencies that obtain Magnet status achieve healthier work environments that often have improved nurse satisfaction, decreased nurse burnout, and better client outcomes. UAP assist nurses to perform client care tasks, including vital signs, but they are not competent to complete patient assessments about functional health patterns. There is a correlation between the number of RNs per client and positive client outcomes. RN-MD collaboration, highly trained nurses, and continuous improvement of clinical work-flow processes are associated with higher- quality patient care per the U.S News & World Report on Best Hospitals in America Honor Role and Centers for Medicare & Medicaid Services.