Chapter 01: Leading, Managing, and Following
Yoder-Wise: Leading and Managing in Nursing, 6th Edition

MULTIPLE CHOICE

	1.	A nurse manager of a 20-bed medical unit finds that 80% of the patients are older adults. She is asked to assess and adapt the unit to better meet the unique needs of the older adult patient. Using complexity principles, what would be the best approach to take in making this change?
a.	Leverage the hierarchical management position to get unit staff involved in assessment and planning.	
b.	Engage involved staff at all levels in the decision-making process.	
c.	Focus the assessment on the unit, and omit the hospital and community environment.	
d.	Hire a geriatric specialist to oversee and control the project.	

ANS:	B
Complexity theory suggests that systems interact and adapt and that decision making occurs throughout the systems, as opposed to being held in a hierarchy. In complexity theory, every voice counts, and therefore, all levels of staff would be involved in decision making.

REF:	Page 8	TOP:	AONE competency: Communication and Relationship-Building

	2.	A unit manager of a 25-bed medical/surgical area receives a phone call from a nurse who has called in sick five times in the past month. He tells the manager that he very much wants to come to work when scheduled but must often care for his wife, who is undergoing treatment for breast cancer. According to Maslow’s need hierarchy theory, what would be the best approach to satisfying the needs of this nurse, other staff, and patients?
a.	Line up agency nurses who can be called in to work on short notice.	
b.	Place the nurse on unpaid leave for the remainder of his wife’s treatment.	
c.	Sympathize with the nurse’s dilemma and let the charge nurse know that this nurse may be calling in frequently in the future.	
d.	Work with the nurse, staffing office, and other nurses to arrange his scheduled days off around his wife’s treatments.	

ANS:	D
Placing the nurse on unpaid leave may threaten the nurse’s capacity to meet physiologic needs and demotivate the nurse. Unsatisfactory coverage of shifts on short notice could affect patient care and threaten the needs of staff to feel competent. Arranging the schedule around the wife’s needs meets the needs of the staff and of patients while satisfying the nurse’s need for affiliation.

REF:	Page 10	TOP:	AONE competency: Communication and Relationship-Building

	3.	A grievance brought by a staff nurse against the unit manager requires mediation. At the first mediation session, the staff nurse repeatedly calls the unit manager’s actions unfair, and the unit manager continues to reiterate the reasons for her actions. What would be the best course of action at this time?
a.	Send the two disputants away to reach their own resolution.	
b.	Involve another staff nurse in the discussion so as to clarify issues.	
c.	Ask each party to examine her own motives and issues in the conflict.	
d.	Continue to listen as the parties repeat their thoughts and feelings about the conflict.	

ANS:	C
Ury, Brett, and Goldberg outline steps to restoring unity, the first of which is to address the interests and involvement of participants in the conflict by examining the real issues of all parties.

REF:	Page 16	TOP:	AONE competency: Communication and Relationship-Building

	4.	At a second negotiation session, the unit manager and staff nurse are unable to reach a resolution. It would now be best to:
a.	Arrange another meeting in a week’s time so as to allow a cooling-off period.	
b.	Turn the dispute over to the director of nursing.	
c.	Insist that participants continue to talk until a resolution has been reached.	
d.	Back the unit manager’s actions and end the dispute.	

ANS:	B
According to the principles outlined by Ury, Brett, and Goldberg, a “cooling-off” period is recommended if resolution fails.

REF:	Page 16	TOP:	AONE competency: Communication and Relationship-Building

	5.	The manager of a surgical area has a vision for the future that requires the addition of RN assistants or unlicensed persons to feed, bathe, and walk patients. The RNs on the staff have always practiced in a primary nursing–delivery system and are very resistant to this idea. The best initial strategy in this situation would include:
a.	Exploring the values and feelings of the RN group in relationship to this change.	
b.	Leaving the RNs alone for a time so they can think about the change before it is implemented.	
c.	Dropping the idea and trying for the change in a year or so when some of the present RNs have retired.	
d.	Hiring the assistants and allowing the RNs to see what good additions they are.	

ANS:	A
Influencing others requires emotional intelligence in domains such as empathy, handling relationships, deepening self-awareness in self and others, motivating others, and managing emotions. Motivating others recognizes that values are powerful forces that influence acceptance of change. Leaving the RNs alone for a period of time before implementation does not provide opportunity to explore different perspectives and values. Avoiding discussion until the team changes may not promote adoption of the change until there is opportunity to explore perspectives and values related to the change. Hiring of the assistants demonstrates lack of empathy for the perspectives of the RN staff.

REF:	Page 7 | Page 15		
TOP:	AONE competency: Knowledge of the Health Care Environment	

	6.	As the RN charge nurse on the night shift in a small long-term care facility, you’ve found that there is little turnover among your LPN and nursing assistant (NA) staff members, but they are not very motivated to go beyond their job descriptions in their work. Which of the following strategies might motivate the staff and lead to greater job satisfaction?
a.	Ask the director of nursing to offer higher wages and bonuses for extra work for the night LPNs and NAs.	
b.	Allow the LPNs and NAs greater decision-making power within the scope of their positions in the institution.	
c.	Hire additional staff so that there are more staff available for enhanced care and individual workloads are lessened.	
d.	Ask the director of nursing to increase job security for night staff by having them sign contracts that guarantee work.	

ANS:	B
Hygiene factors such as salary, working conditions, and security are consistent with Herzberg’s two-factor theory of motivation; meeting these needs avoids job dissatisfaction. Motivator factors such as recognition and satisfaction with work promote a satisfying and enriched work environment. Transformational leaders use motivator factors liberally to inspire work performance and increase job satisfaction.

REF:	Page 9 | Page 10		
TOP:	AONE competency: Communication and Relationship-Building	

	7.	As the nurse manager who wants to increase motivation by providing motivating factors, which action would you select?
a.	Collaborate with the human resource/personnel department to develop on-site daycare services.	
b.	Provide a hierarchical organizational structure.	
c.	Implement a model of shared governance.	
d.	Promote the development of a flexible benefits package.	

ANS:	C
Complexity theory suggests that systems interact and adapt and that decision making occurs throughout systems, as opposed to being held in a hierarchy. In complexity theory, every voice counts, and therefore all levels of staff would be involved in decision making. This principle is the foundation of shared governance.

REF:	Pages 8-11	TOP:	AONE competency: Communication and Relationship-Building

	8.	A charge nurse on a busy 40-bed medical/surgical unit is approached by a family member who begins to complain loudly about the quality of care his mother is receiving. His behavior is so disruptive that it is overheard by staff, physicians, and other visitors. The family member rejects any attempt to intervene therapeutically to resolve the issue. He leaves the unit abruptly, and the nurse is left feeling frustrated. Which behavior by the charge nurse best illustrates refined leadership skills in an emotionally intelligent practitioner?
a.	Reflect to gain insight into how the situation could be handled differently in the future.	
b.	Try to catch up with the angry family member to resolve the concern.	
c.	Discuss the concern with the patient after the family member has left.	
d.	Notify nursing administration of the situation.	

ANS:	A
Goleman suggests that emotional intelligence involves insight and being able to step outside of the situation to envision the context of what is happening as well as being able to manage emotions such as frustration effectively.

REF:	Page 7 | Page 8		TOP:	AONE competency: Leadership

	9.	The chief nursing officer has asked the staff development coordinator to facilitate the development of a clinical competency program for the facility. While making rounds on the units, the staff development coordinator overhears RN staff complaining that they feel it is insulting to be required to participate in a competency program. Which behavior by the staff development coordinator is most appropriate in this situation?
a.	Disregard staff concerns and continue with development of the program.	
b.	Inform the nurses that this program is a requirement for JCAHO accreditation.	
c.	Schedule a meeting with the chief nurse executive to apprise her of the situation.	
d.	Facilitate a meeting so nurses can articulate their values and concerns about a competency program.	

ANS:	D
The manager role involves guiding others through a set of derived practices that are evidence-based and known to satisfy preestablished outcomes such as participation in a competency program. This involves engagement of staff through sharing of concerns and ideas. A close analysis of the IOM report and the summary of the PPACA suggests that no health reform can unfold without active nursing engagement. Each document emphasizes that nurses must lead, manage, and behave as active collaborators with other members of the health team and with those being served.

REF:	Page 3	TOP:	AONE competency: Communication and Relationship-Building

	10.	As the manager, you have been asked to implement an evidence-based approach to teach ostomy patients self-management skills postoperatively that is being operationalized throughout your organization. Which of the following illustrates effective leadership?
a.	The training modules are left in the staff room for times when staff are available.	
b.	The current approach is continued because it is also evidence-based and is more familiar to staff.	
c.	You decide to implement the approach at a later date because of feedback from the RNs that the new approach takes too much time.	
d.	A RN who is already familiar with the new approach volunteers to take the lead in mentoring and teaching others how to implement it.	

ANS:	D
Followership occurs when there is acquiescence to a peer who is leading in a setting where a team has gathered to ensure the best clinical decision making and actions are taken to achieve clinical or organizational outcomes. Followership promotes good clinical decisions and use of clinical resources.

REF:	Page 4 | Page 5		
TOP:	AONE competency: Communication and Relationship-Building	

	11.	You overhear a newly graduated RN telling one of your colleagues that leadership and management belong to the unit manager and not to her. As a nursing colleague, you respond by demonstrating understanding that the perception of the new graduate:
a.	Is correct. Leadership is not the role of the staff nurse.	
b.	Would benefit from further understanding of her role as a professional, whose influence may affect the decision making of patients, colleagues, and other professionals.	
c.	Has been influenced by nurse leaders and managers who leave for other positions.	
d.	Is related to the general perception that nurse leaders and managers are not satisfied in their jobs.	

ANS:	B
Care coordination that involves the intersection of individual, family, and community-based needs requires that nurses have self-confidence, knowledge of organizations and health systems, and an inner desire to lead and manage. There is often a view that leadership is isolated to those holding managerial positions and that a direct care nurse is subject to following by adhering to the direction of others. Such views fail to acknowledge that to be a nurse requires each licensed individual to lead, manage, and follow when practicing at the point-of-care and beyond.

REF:	Page 3 | Page 4		TOP:	AONE competency: Leadership

	12.	You walk into Mr. Smith’s room and find him yelling at the LPN, Miss Jones. He is obviously very upset and after you speak with him regarding his behavior, you determine that he has not slept for three nights because of unrelieved pain levels. The LPN is very upset with Mr. Smith and calls him an “ugly, old man.” You acknowledge her feelings and concerns and then suggest that Mr. Smith’s behavior was aggressive but is related to lack of sleep and to pain. You say to Miss Jones, “Can you both, together with Mr. Smith, determine triggers for the pain and effective approaches to controlling his pain?” This approach demonstrates:
a.	Lack of empathy and understanding for Miss Jones.	
b.	Concern with placating Mr. Smith.	
c.	Leadership behavior.	
d.	Management behavior.	

ANS:	C
The situation between Mr. Smith and Miss Jones is a complex situation involving unrelieved patient symptoms and aggressiveness toward a staff member. Providing engaged, collaborative guidance and decision making in a complex situation where there is no standardized solution reflects leadership.

REF:	Page 4	TOP:	AONE competency: Leadership

	13.	After assessing an older adult patient in long-term care who has been slowly deteriorating for weeks, the nurse manager calls the family and asks them to come in, as the patient is dying. The nurse manager’s decision and actions are based on:
a.	An established clinical pathway.	
b.	Confirmatory scientific evidence.	
c.	Unit protocol.	
d.	Experience.	

ANS:	D
The nurse manager is employing knowledge and experience in determining that the patient is dying, because the course of dying is not standardized and cannot be determined by clinical pathways.

REF:	Page 4	TOP:	AONE competency: Knowledge of the Health Care Environment

	14.	Chart audits have revealed significant omissions of data that could have legal and funding guidelines ramifications. As the unit manager, you meet with the staff to discuss audit findings and to find approaches that will address the gaps in charting and achieve desired goals. This is an example of:
a.	Leadership.	
b.	Management.	
c.	Decision making.	
d.	Vision.	

ANS:	B
The process of guiding others to meet established goals, outcomes, and procedures is management. This can require collaborative decision making to determine how best to reach pre-determined goals and follow established practices.

REF:	Page 5	TOP:	AONE competency: Knowledge of the Health Care Environment

	15.	A family is keeping vigil at a critically ill patient’s bedside. Other, distant family members, not yet able to come, call the unit continuously, asking for updates and wanting to express concern. You speak with the distant family members and suggest that you are going to refer them to the hospital social worker, whose role is to work with people in such situations. What role are you assuming through this action?
a.	Manager	
b.	Leader	
c.	Follower	
d.	Laissez-faire	

ANS:	A
As a manager, you are concerned with managing and coordinating resources to achieve outcomes in accordance with established clinical processes. Referral to a social worker alleviates demand on staff time and is consistent with hospital procedures.

REF:	Page 5	TOP:	AONE competency: Communication and Relationship-Building

	16.	A family is keeping vigil at a critically ill patient’s bedside. Other, distant family members, not yet able to come, call the unit continuously, asking for updates and wanting to express concern. You speak with the distant family members and suggest that you are going to refer them to the hospital social worker, whose role is to work with people in such situations. In response to this situation, you approach the unit manager to apprise her of your concerns that the family dynamics of the patient involved may lead to staff-family and patient-family conflicts. You suggest that the physician may need to discuss the treatment plan with the family. The unit manager advises that he will arrange this discussion. If, after the meeting with family members, this is identified as a desired approach, you support the manager’s decision. Your actions indicate that you are acting in what role?
a.	Leadership	
b.	Management	
c.	Follower	
d.	Evidence-based	

ANS:	C
In the followership role, you bring to the manager your concerns about potential litigation and maximization of outcomes and accept the direction given by the manager in response to your concerns.

REF:	Page 3 | Page 4		
TOP:	AONE competency: Knowledge of the Health Care Environment	

	17.	You pull staff together to assess a situation in which the family of a seriously ill patient is anxious and is absorbing a great deal of staff time in consultation, discussion, and questioning of treatment decisions. Staff members are becoming distanced from the family. After inviting the concerns of staff, you explain that the organization values patient-centered care and that evidence supports that acting as an advocate and a listener is helpful to families. You ask the staff for ideas as to strategies that are effectively patient-centered in these situations. In this situation, you are taking on which role?
a.	Leadership	
b.	Management	
c.	Follower	
d.	Visionary	

ANS:	A
As a leader, you provide and communicate vision and direction based on evidence and experience, and you engage others in decision making that moves them toward the vision with a reasonable level of risk taking.

REF:	Page 4 | Page 5		TOP:	AONE competency: Leadership

	18.	Joan, the nursing unit manager, finds it difficult to work with Thomas, a new graduate. Thomas has many ideas, and his manner of presenting them irks Joan. After reflection and discussion with others, Joan recognizes that she also feels threatened by his behavior. She comes to understand that Thomas is trying to establish his own role on the unit, is not trying to challenge her, and needs guidance, coaching, and affirmation. Joan is demonstrating:
a.	A positive self-concept.	
b.	Deepening self-awareness.	
c.	Leadership.	
d.	Acquiescence.	

ANS:	B
According to Goleman (1995), stepping outside oneself to envision the situation while assuming ownership is a component of emotional intelligence.

REF:	Page 7 | Page 8		TOP:	AONE competency: Professionalism

	19.	As the head of a nursing program, you consistently invite the ideas of your team about innovations in teaching, community partnerships, and curriculum design and invite participation in decisions. Many of these ideas have been implemented successfully, and your staff members are keen to try on other ideas. You are employing _____ leadership.
a.	Situational	
b.	Trait-based	
c.	Contingency-based	
d.	Transformational	

ANS:	D
Transformational leadership involves attending to the needs and motives of followers, which results in creativity, improvement, and employee development.

REF:	Page 10 | Page 11		TOP:	AONE competency: Professionalism

	20.	As a leader on a rehab unit, you encourage all staff members to see themselves as having a role in decision making and quality care. You see your role as involving particular responsibilities in decision making but not as a hierarchal role. This view of decision making and leadership is consistent with:
a.	Trait theories.	
b.	Complexity theory.	
c.	Situated theory.	
d.	Emotional intelligence.	

ANS:	B
Complexity theory involves envisioning each member of the team involved in decision making, management, and leadership, with the leader not seen in a hierarchal relationship to other team members.

REF:	Pages 8-11	TOP:	AONE competency: Leadership

	21.	You recently acquired a position as a unit manager. During your time on the unit, you have formed a strong social network among your staff, have promoted the development of relationships between your staff and workers in other areas of the organization, and have formed relationships that generate ideas from patient organizations and the local nursing education program. According to complexity theory, you are engaging which principle?
a.	Empowerment	
b.	Systematic thinking	
c.	Development of networks	
d.	Bottom-up interactions	

ANS:	C
According to complexity theory, social networks evolve around areas of common interest and are able to respond to problems in creative and novel ways.

REF:	Page 12	TOP:	AONE competency: Knowledge of the Health Care Environment

	22.	According to the complexity theory, which of the following should be the focus of measurement?
a.	Cost per hospital day	
b.	Bed utilization	
c.	Infection rates	
d.	Staff morale and budgets	

ANS:	D
According to complexity theory and the principle “Think systematically,” you cannot ignore objective data or nonmeasurable data, as both inform decisions.

REF:	Page 13	TOP:	AONE competency: Business Skills		

	23.	During a staff meeting held to discuss developing a mission statement for the unit, the idea of placing patient needs first is:
a.	Empowering.	
b.	A leadership tag.	
c.	A symbol.	
d.	A management task.	

ANS:	B
According to complexity theory, leadership tags, which are similar to values, reflect the patient-centered philosophies and values-driven characteristics that define an organization and give it personality.

REF:	Page 12	TOP:	AONE competency: Knowledge of the Health Care Environment

	24.	A dispute arises between an RN staff member and an LPN over a patient issue. The tension between the two begins to affect other staff members, who are drawn into the conflict; eventually, the team becomes polarized toward either the RN or the LPN. This situation might have been prevented through:
a.	Expediency in responding to the initial dispute, once it became apparent that it could not be resolved by the two parties themselves.	
b.	Asking other staff members what the real issues were in the dispute between the RN and the LPN.	
c.	Reassigning one of the parties to another unit when it became apparent that the two individuals could not resolve the dispute themselves.	
d.	Calling a staff meeting at the onset of the dispute to allow the team and the RN and LPN to discuss the initial dispute.	

ANS:	A
The initial step in conflict resolution should have involved an expedient response to the issues and putting a focus on the issues involved in the dispute between the LPN and RN through negotiation involving the two parties, before the dispute involved others.

REF:	Page 16	TOP:	AONE competency: Communication and Relationship-Building

	25.	The unit is shifting from primary nursing to a team model in an effort to contain costs. Staff members are angry and ask for a meeting to discuss the change. After hearing their concerns related to reduction in professional autonomy and care quality, you:
a.	Acknowledge the loss.	
b.	Explain the reasons for change, emphasizing the need to reduce costs.	
c.	Repeat the information several times, giving detailed budget overviews.	
d.	Adjourn the meeting and provide explanation through e-mail.	

ANS:	A
Visioning involves engaging with others to assess the current reality, specify the end point, and then strategize to reduce differences. This requires trusting relationships that acknowledge the differences in values and ideas. When done well, the nurse and the nurses within a unit experience creative tension that inspires working in concert to achieve desired goals.

REF:	Page 15	TOP:	AONE competency: Communication and Relationship-Building

MULTIPLE RESPONSE

	1.	Sarah wonders about the direction that you have given regarding management of incontinent, confused patients. She brings you evidence that she has found regarding incontinence interventions and asks you if she and you could talk about the guidance that you have given after you have had an opportunity to read the articles she has given you. This is an example of (select all that apply):
a.	Assertiveness.	
b.	Followership.	
c.	Management.	
d.	Insubordination.	

ANS:	A, B
This is an example of followership in which a staff nurse is demonstrating assertive behavior and presenting evidence that may influence the decision making of her nurse leader and manager.

REF:	Page 5	TOP:	AONE competency: Knowledge of the Health Care Environment