Leadership vs. Management: Critical Thinking in Nursing, Exams of Nursing

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EDAPT – THE NURSE AS LEADER

“Management is efficiency in climbing the ladder of success; leadership determines whether the ladder is leaning against the right wall.” As described in the quote, being a leader is different than being a manager. Of course, most leaders also manage, and most managers also lead, yet the skill sets for each are unique. DIFFERENCES BETWEEN LEADERS AND MANAGERS For each characteristic, specify if it aligns with a leadership or management position. Managers focus on guiding colleagues to complete tasks that support organizational goals. Managers have control over directing subordinates and manipulating their resources to achieve goals and emphasize control and results. Leaders focus on inspiring others to follow a shared vision but have less delegated authority. Leaders hold a more informal role within the organization and emphasize interpersonal relationships. Both are needed within a successful organization and can be part of the formal hierarchy (e.g., organizational chart) of business. Leaders, however, may not hold a recognized leadership position. Leadership Management Less delegated authority x Direct subordinates x Emphasizes control and results x Emphasizes interpersonal relationships x Manipulate resources to achieve goals x May or may not be part of the formal hierarchy of the organization x Which skill is a basic requirement for the development of sound critical thinking? Critical thinking, sometimes referred to as reflective thinking, is related to evaluation and has a broader scope than decision making and problem solving. Which process is not used to support decision making by the nurse and nurse leader? Assuming can prevent the nurse from questioning the facts of a situation, which leads to poor decisions. If a manager guides, directs, motivates, and empowers others, then it could be said that every manager should be a leader. Similarly, leadership without management results in chaos and failure for both the organization and the individual executive.

Current leadership theory views leaders as those who guide workers to embrace and work towards the goals of an organization by setting an example. Managers , on the other hand, are those who supervise processes and direct workers to meet the goals of the organization. Yet the reality is that any nurse who has direct reports must be able to both supervise people and processes and be an example that guides others to support the organization. Management

• Supervises processes
• Directs workers Leadership
• Sets examples
• Guides workers No organization can thrive and grow without the contributions of both leaders and managers. Roles of Managers
• Are assigned a position by the organization
• Have a legitimate source of power due to delegated authority that accompanies their position
• Have specific duties and responsibilities they are expected to carry out
• Emphasize control, decision making, decision analysis, and results
• Manipulate people, the environment, money, time, and other resources to achieve the goals of the organization
• Have a greater formal responsibility and accountability for rationality and control than leaders
• Direct willing and unwilling subordinates Roles of Leaders
• Often do not have delegated authority but obtain power through other means, such as influence
• Have a wider variety of roles than managers
• Focus on group process, information gathering, feedback, and empowering others
• May or may not be part of the formal hierarchy of the organization
• Emphasize interpersonal relationships So, what is the difference? According to a popular online dictionary (Merriam-Webster, n.d.-a; Merriam-Webster, n.d.-b), the difference is in the focus of the actions. Manager: one that manages Management: the act or art of managing: the conducting or supervising of something (such as a business) Lead: to guide on a way especially by going in advance Leadership: the act or instance of leading

• Direct willing followers
• Have goals that may or may not reflect those of the organization In many successful organizations, leaders can be found in designated leadership positions or working in subordinate positions. No matter their position in the organization, leaders inspire trust and motivate others to actively support their vision. FORMAL LEADERS Formal leaders hold positions of authority within the organization and are expected to influence, empower, and manage others (Ross, 2014). Examples of formal leaders include the Chief Academic Officer of a college of nursing, a unit nurse manager, and a shift nursing supervisor. INFORMAL LEADERS Informal leaders are those who have influence over their peers, despite not being in an organizationally recognized position of authority (Lawson et al., 2018). Examples of informal leaders include a staff nurse whose peers seek their input on returning to school, or a licensed practical nurse who encourages a colleague to join a unit’s shared governance committee. A nurse is appointed to a charge nurse position in a local hospital. Which term best describes this new role? Formal leaders hold positions of authority within the organization in which they are expected to influence, empower, and manage others (Ross, 2014). This is usually accomplished by appointment (or assigned) by those holding higher positions within the organization. Three related skills required by a successful nurse are the ability to make decisions, solve problems, and think critically (Marquis & Huston, 2020; Social Science, 2020). Often used interchangeably, these skills are closely related yet unique. Together, critical thinking, problem-solving, and decision-making form the basis for clinical reasoning. CRITICAL THINKING Used for both decision-making and problem-solving, critical thinking is the way a person takes control of thinking using an intellectual process. This structured thinking raises vital questions used to gather relevant information with an open mind (The Foundation for Critical Thinking, n.d.). The person who thinks critically uses the information gathered alone, or with others, to reach solutions to complex problems. The advantage of using critical thinking in nursing, whether as a staff nurse or nurse leader, is that it helps the nurse understand the current situation or need, consider what it means to the client or staff, examine the available evidence and current reasoning, and reach a judgement. PROBLEM-SOLVING

Seeking to eliminate a problem or issue, problem-solving is a systematic process used to complete a full analysis of all known data. The goal is to discover the root cause of an issue and ends when a decision is made on how to proceed. Critical thinking supports problem-solving when nurses ask questions and keep open minds to gather all relevant data. DECISION-MAKING Decision-making is a cognitive process influenced by a person’s value system, used to select a course of action to eliminate a problem. Although decision-making is the final step in the problem-solving process, it is possible to make decisions without understanding the root cause, including during an emergency situation for which a protocol is used. For example, when the nurse finds an unresponsive client, cardiopulmonary resuscitation (CPR) is started with an assessment of the airway. In this instance, following a CPR algorithm (list of all tasks to follow) replaces decision-making in order to save a life. By following an algorithm, decision-making by the individual nurse has been removed. Evidence-based research has already determined the best course of action. This is crucially important when life-saving measures are needed. Critical thinking is used in decision-making to determine the root cause of an issue when an immediate decision is not required, or a protocol is in place. The nurse leader uses the same process for decision-making as the staff nurse, but with a different focus. Where the staff nurse’s decisions concern client care, the nurse manager attends to the details that allow a nursing unit to run smoothly. For both nurse leaders and staff nurses, the use of a structured decision-making process ultimately guides the nurse’s attention to the process, organizes thoughts, and helps offset human error through the structured critical thinking process. Define Objectives Clearly

• If a decision lacks a clear objective or if an objective is not consistent with the individual’s or organization’s stated philosophy, a poor-quality decision is likely to be made. Gather Data Carefully

• Sources of data available for a nurse leader include clients, staff, reports on unit activity, and information shared by their peers.
• Facts can be misleading if they are presented in a suggestive manner, taken out of context, or are past- oriented.
• Pre-conceived ideas or personal values could alter how data is interpreted, which may lead to bias in decision making. Take the Time Necessary
• Devoting time to reflect on all aspects of the situation allows for the facts and variables that matter most to be considered, which results in fewer bad decisions.
• Use an Evidence-Based Approach
• Evidence-based decision making and evidence-based practice should be viewed as imperatives for all nurses today as well as for the profession in general. Generate Many Alternatives
• The greater the number of alternatives that can be generated, the greater the chance that the final decision will be sound. Think Logically
• By thinking carefully through the information and alternatives, decision making avoids illogical thinking (e.g., overgeneralizing, affirming the consequence, and arguing an analogy). Choose and Act Decisively
• When the client's family is included in making health care choices, disagreements can delay the final decision.
• Many individuals, nurses and clients included, choose to delay acting because they lack the courage to face the consequences of their choices.

The nurse leader is orienting a new charge nurse to the expected decision-making process they will share. Which of the following are the benefits of using a structured approach to decision-making? Select all that apply. Using a structured decision-making process focuses the nurse’s attention to the process, organizes thoughts, and helps offset human error by promoting the critical thinking process. No decision-making process can remove human error. A structured approach can offset it, though. Whether it is a nurse providing care to clients or a nurse leader overseeing the nursing staff, identifying and solving a problem are crucial skills known as critical thinking or reflective thinking. What separates critical thinking from problem-solving and decision-making is the purposeful search for the meaning of the evidence —by analyzing cues and evaluating outcomes—to determine if more evidence is needed for decision-making or problem-solving. Self-reflection is often used after a decision has been made to determine if the intended outcomes were met. The nurse uses self-reflection to understand how to change their own behaviors when similar situations arise in the future. Known as cognitive processes, the six steps of critical thinking are Cognitive Process Dimensions: Focus is on the thinking used to critically think.

• Recognize Cues: What matters most?
• Analyze Cues: What could it mean?
• Prioritize Hypotheses: Where do I start?
• Generate Solutions: What can I do?
• Take Action: What will I do?
• Evaluate Outcomes: Did it help? Clinical Judgement (Nurse): Cognitive processes of critical thinking applied to client care.
• Recognize Cues: The client has left-sided face and arm weakness, tingling, fatigue, dizziness, and confusion.
• Analyze Cues: This could be a stroke, Gullain-Barré syndrome, or Bell’s palsy.
• Prioritize Hypotheses: The symptoms are most like a stroke.
• Generate Solutions: Need to call health care provider, initiate rapid response team, and keep client on bedrest.
• Take Action: Perform focused neurologic exam, and diagnostic testing as ordered.
• Evaluate Outcomes: Evaluate the client’s condition after intervention as compared to when symptoms first noted. Critical Thinking (Leader): Cognitive processes applied to managing a nursing unit.
• Recognize Cues: There are increased post-operative infections over the last 3 months.
• Analyze Cues: The analysis involve clients from two surgeons, all operations on lower extremities, and all emergency surgeries.

• Prioritize Hypotheses: Prioritize surgeon error, contaminated orthopedic surgical tools, and issue with dressing changes on unit.
• Generate Solutions: Establish new process for surgical scrubs and decontamination of surgical equipment, and validate nurse competency changing dressings.
• Take Action: Meet with quality improvement nurse, operating room manager, and unit staff.
• Evaluate Outcomes: Evaluate infection rates after intervention as compared to when increase was noted. In which situation is the nurse demonstrating self-reflection to improve critical thinking? Highlight the correct response. Revises a plan of care aker noting the client's response to interventions Self-reflecting, or thinking back, on the effectiveness of interventions (evaluation of outcomes) and how they were performed allows the nurse to identify flawed thinking and take steps to think differently in the future. In other words, aker self-reflection, the nurse was able to revise the plan of care based on client responses. Critical thinking and decision-making are both cognitive processes that require thought. Which cognitive process steps are unique to critical thinking? Select all that apply. Analysis and evaluation are both higher order thinking skills that require disciplined thinking informed by evidence. When analyzing cues and evaluating outcomes, the nurse forms judgements based on what the cues, or assessment findings, mean for each client. Analyzing cues allows the nurse to determine the client’s priority health problems. Evaluating outcomes provides evidence on how the client is responding to care. When people fail to think critically, the results are often dangerous and costly (Insight Assessment, n.d.). For example, bad decisions in business can lead to failed systems. When creating healthcare policy, bad decisions can lead to health inequities. And when providing client care, bad decisions can result in disability or death. Weakness in critical thinking in the healthcare setting may lead to lost opportunities, increased cost of care, decreased interprofessional collaboration, and loss of life. Too often, poor thinking is discovered after a bad decision is made and a client has been affected. When that happens, the nurse may ask themselves, “What was I thinking?” Nurses with poor critical thinking skills may fail to detect a patient in distress or deteriorating condition. This can result in a failure-to-rescue (FTR), which can result in complications or mortality. In The Essentials: Core Competencies for Professional Nursing Education , the American Association of Colleges of Nursing (2021) includes demonstrating intellectual curiosity, examining the influence of personal values in decision making, and having a framework for making ethical decisions as crucial competencies for entry-level professional nursing education. These three competencies promote critical thinking and the provision of safe- effective nursing care.

Completing a client assessment (gathering data) is the best way to detect deterioration of the client’s status, even if the nurse is not certain what is causing the change. Critical thinking skills help the nurse figure out what additional information is needed to provide the safest care possible. The nurse manager who overheard a nurse saying, “men have such a low tolerance for pain” realizes that the nurse’s clients are at risk for harm due to which factor? Preconceived ideas, like generalizing that all men have a low pain tolerance, can alter how the nurse interprets data related to the male client's experience of pain, resulting in poor decision-making. This implicit bias may result in the client being over- or under-medicated. For each question, specify if the statement demonstrates if the nurse is or is not using critical thinking. What separates critical thinking from problem-solving and decision-making is the purposeful search for the meaning of the evidence—by analyzing cues and evaluating outcomes—to determine if more evidence is needed for decision-making or problem-solving. Self-reflection is oken used aker a decision has been made to determine if the intended outcomes were met. The nurse uses self-reflection to understand how to change their own behaviors in similar, future situations. Statement Status Rationale “That did not work well. How can I do it differently next time?” Is using critical thinking The nurse is thinking about how the current outcome can help improve the care they provide for future clients. “That chair has had a broken leg for a while. When will someone do something about it?” Is not using critical thinking The nurse’s statement implies they see a safety hazard, knows something should be done, but seems not to consider that they should report the concern themselves. “This should help the client, but is it safe?” Is using critical thinking This nurse is considering how a potential action will impact the client’s safety. “The facts are there, but what do they mean for this person’s health?” Is using critical thinking In this instance, the nurse is using critical thinking to understand what the evidence reveals about someone’s health. “Why does nothing go right for me? Is not using critical thinking This question focuses on outcomes that impact the nurse, rather than the client. If the nurse were focusing on the client, they may ask, “Why is nothing being done to improve this person’s pain?” The nurse leader is mentoring a new nurse whose clinical reasoning skills are limited. Before creating an improvement plan, which three skills of the new nurse should be evaluated by the nurse leader?

Critical thinking, problem-solving, and decision-making form the basis for clinical reasoning. When a new nurse has limited experience using these skills in client care situations, it is important that the nurse leader understands the new nurse’s current level of competence with each before creating an improvement plan. Choose the answer from the drop down box A nurse leader demonstrates leadership characteristics by fostering interpersonal relationships (attending new colleague orientation) and seeking feedback (“Pulse Check” survey). These actions inspire trust in others and set an example for colleagues to follow. The nurse leader who makes decisions without input from subordinates (seṄng a schedule for breaks and changing normal work hours) and manipulates their behaviors (offering bonuses to complete work) is demonstrating management characteristics. While it may appear that leadership is more desirable, or positive, than management, one must keep in mind that each has a place within an organization, even within one individual who has direct reports. Leaders inspire while managers make sure work gets done. Leaders see what can be, so managers can turn the dream into reality. A staff nurse who serves on the facility policy and procedure committee encourages a colleague to volunteer to fill a recently opened position on the same committee. Which role is this colleague demonstrating? An informal leader has influence over their peers despite not being in an appointed position of authority (Lawson et al., 2008). By encouraging a colleague, the nurse is acting as an informal leader. The nurse manager has received feedback from their mentor that the quality of decisions the nurse manager makes could be improved using critical thinking. Which actions should the mentor recommend the nurse manager take to increase their competence? Select all that apply. Critical thinking, a component of decision-making, is how a person takes control of thinking using an intellectual process. Asking many questions is used to gather relevant information with an open mind. The greater the number of alternatives generated, the greater the chance that the final decision will be sound. Critical thinking and seeking input from others (without limiting to a specific number) for ideas as needed supports making the best decision. The ethics committee is reviewing a recent decision involving a family whose father was at the end of his life, and the adult children could not agree on a treatment plan. The client’s nurse, who was present for the consultation and contributed to the discussion, asks the medical ethicist why families struggle with a decision that seems clear to the nurse. Which statement is the best response by the medical ethicist? Decision-making is a cognitive process influenced by a person’s value system, used to select a course of action to eliminate a problem. Family members oken have strong values that may vary from person to person. When discussing end-of-life issues, the values, mixed with strong emotions, can delay, or even cloud, final decisions. In which situations should the nurse leader use critical thinking? Select all that apply.

During an investigation of uncharged care items When selecting which job applicant to hire Critical thinking should be used when solving problems (investigating uncharged care items) and making decisions related to complex situations (selecting the best job applicant to work on the unit). Oken used by nurses when providing client care, the nurse leader extends critical thinking to help the nursing unit function smoothly while promoting safety and positive outcomes.