Readings· Marquis, B. L., & Huston, C. J. (2012). Leadership rol.docx

Readings
· Marquis, B. L., & Huston, C. J. (2012). Leadership roles and
management functions in nursing: Theory and
application (Laureate Education, Inc., custom ed.).
Philadelphia, PA: Lippincott, Williams & Wilkins.
. Chapter 2, “Classical Views of Leadership and Management”
The information introduced through this chapter relates to this
week’s Discussion, and will also be referred to in future weeks
of the course.
. Chapter 3, “Twenty-First Century Thinking About Leadership
and Management”
This chapter examines new thinking about leadership and
management and how this may influence the future of nursing.
. WReview Chapter 12, “Organizational Structure”
· Berggren, I., & Carlstrom, E. (2010). Decision making within
a community provider organization. British Journal of
Community Nursing, 15(12), 611–617.
Retrieved from the Walden Library databases.
Berggren and Carlstrom interviewed six nurses in two
communities to explore the nurses’ experiences with decision
making in their workplace.
· Downey, M., Parslow, S., & Smart, M. (2011). The hidden
treasure in nursing leadership: Informal leaders. Journal of
Nursing Management, 19(4), 517–521.
Informal leaders can have a strong impact in the workplace.
This article explores the value informal leaders can provide.
· Madden, A. (2011). EHR adoption: Help is here for your
decision-making process. Tennessee Medicine, 104(9), 35, 37.

Madden’s article analyzes the decision-making process that
comes with EHR adoption. To successfully implement EHR, she
recommends that clear goals be set, that an interdisciplinary
team be formed with at least one lead physician, and that a
system is chosen based on the needs of the practice.
· http://www.amazon.com/Essentials-Nursing-Informatics-6th-
Edition/dp/0071829555/ref=dp_ob_title_bk
The hidden treasure in nursing leadership: informal leaders
MARTY DOWNEY P h D , R N 1, SUSAN PARSLOW P h D ,
R N 1 and MARCIA SMART P h D , M B A 2
1Associate Professor of Nursing, Boise State University, Boise,
ID and 2Leadership Strategist, Smart Leadership
Solution
s, Boise, ID, USA
Informal leaders
In today�s complex, dynamic healthcare management
environment, it is imperative that nurse managers take a
more focused look at nursing leadership within the

arena of direct patient care in their organizations.
The current and evolving nursing shortage, as well as
the uncertainty of the healthcare climate, is creating
significant challenges to contemporary nurse manage-
ment and leadership. The goal of the present article was
to generate awareness of characteristics of informal
leaders in health care with the emphasis on nurses in
acute care settings. To discuss this phenomenon,
informal interviews took place with nurse managers in
two large urban medical centres in the United States
mountain west.
Now, more than ever, nursing needs energetic, com-

mitted and dedicated leaders to meet the challenges of
the healthcare climate and the nursing shortage. This
article presents a very important, timely and alternative
perspective to assist nurse managers dealing with cur-
rent challenges.
Correspondence
Marty Downey
Boise State University
1910 University Drive
Boise
ID 83725-1840
USA
E-mail: [email protected]

D O W N E Y M . , P A R S L O W S . & S M A R T M . (2011)
Journal of Nursing Management 19, 517–
521
The hidden treasure in nursing leadership: informal leaders
Aim The goal of the present article was to generate awareness
of characteristics of
informal leaders in healthcare with the emphasis on nurses in
acute care settings.
There is limited research or literature regarding informal
leaders in nursing and how
they positively impact nursing management, the organization
and, ultimately,
patient care. Identification of nurses with leadership
characteristics is important so
that leadership development and mentoring can occur within the
nursing profession.
Background More than ever, nursing needs energetic, committed
and dedicated

leaders to meet the challenges of the healthcare climate and the
nursing shortage.
This requires nurse leaders to consider all avenues to ensure the
ongoing profit-
ability and viability of their healthcare facility.
Key issues This paper discusses clinical nurses as informal
leaders; characteristics of
the informal nurse leader, the role they play, how they impact
their unit and how
they shape the organization.
Implication for nursing management Informal nurse leaders are
an underutilized
asset in health care. If identified early, these nurses can be
developed and empow-
ered to impact unit performance, efficiency and environmental
culture in a positive

manner.
Keywords: informal leaders, informal nurse leaders, informal
leadership, leadership in
healthcare, nursing management, nursing leadership
Accepted for publication: 18 February 2011
Journal of Nursing Management, 2011, 19, 517–521
DOI: 10.1111/j.1365-2834.2011.01253.x
ª 2011 The Authors. Journal compilation ª 2011 Blackwell
Publishing Ltd 517
Shortell and Kaluzny (2000) describe Leadership as a
process through which an individual attempts to
intentionally influence others to accomplish a goal. A
great deal has been written about nursing leadership,

ranging from its impact on the nursing shortage, job
satisfaction, retention and turnover to patient safety
and outcomes. Others have focused on nursing leader-
ship competencies and behaviours as well as pathways
to leadership positions and education requirements. The
literature and research generally focuses on formal
leadership (Cummings et al. 2008). However, there is
very little, if any, literature or research regarding
informal leaders in nursing and how they might posi-
tively impact nursing management, the organization
and ultimately, patient care. It is vital to the future of
the nursing profession that those with leadership char-
acteristics are identified for development and mentoring

to occur.
There is no question that positive nursing leadership
is a critical component of a successful health care
organization. On the other hand, what about the
informal leader and their impact on the organization?
This question is the focus of the present investigation.
In a landmark study on leadership, Dr Marcia Smart
(2005) researched an evolving phenomenon called
�Informal Leadership�. Outside the boundaries of formal
authority is a phenomenon, in which leadership is dri-
ven by a network of people who make things happen
primarily through subtle power and influence.
Approximately 80–90% of a typical health-care orga-

nization is non-management, and within this large
group are individuals who have the power and influence
to impact the level and quality of patient care at the
bedside (Lee & Cummings 2008). Anticipating the de-
mands for future nurse leaders, nurse managers should
consider identifying these individuals and begin defining
the roles they play in leadership. Additionally, nurse
leaders and managers should strive to understand how
informal nurse leaders gain their power and influence
and focus on the ways they can be mentored and sup-
ported.
Informal nurse leaders a hidden treasure

Smart (2005) stated that within most organizations
there lies a behind-the-scenes �shadow� organization
made up of people and informal networks of people.
The leadership phenomenon within this network of
people and its cohorts is referred to as �informal lead-
ership�. At the heart of the informal network is the
informal nurse leader (INL).
Officially, every facility and unit has a formal orga-
nizational chart that delineates responsibilities and
identifies the chain of command. However, the manner
in which work is truly accomplished often follows an
undocumented and unacknowledged path, guided by
these individuals, the informal leaders, who are both
heavily relied upon and often taken for granted.

Informal leaders are individuals without formal title
or authority who serve as advocates for the business,
and heighten the contributions of others as well as their
own primarily through influence, relationship-building,
knowledge and expertise (Smart 2010).
Informal nurse leaders are ubiquitous, once they are
discovered. They represent an overlooked resource that
could be developed and supported to great advantage
by any manager savvy enough to take the time to
understand who they are, the roles they play and how
they function. Informal leaders rarely have the kind of
explicit qualifications that can be easily documented or
communicated, much less evaluated (Katzenbach &

Khan 2010). However, nurse managers equipped with
this understanding can appropriately identify, support,
reward and develop informal leaders.
How to identify informal leaders
Identifying informal leaders may appear to be a simple
process. It is often assumed that the person who is out
front, speaks up more often or seems to have the most
overt relationship with management would be an
informal leader. This assumption may not necessarily be
the case. In discussions with acute care nurse managers,
it was agreed upon that a critical distinction of informal
leadership is �influence�. Smart (2010) defines influence
as the power to affect other people�s thinking and/or

actions. Nurse managers can identify the influence of
informal leaders in the acute care setting primarily
through observation. Having an understanding of the
factors that contribute to nursing leadership is funda-
mental to ensuring a future supply of nurse leaders who
can positively influence outcomes for health care pro-
viders and patients (Cummings et al. 2008).
Informal leaders generally do not have formal titles as
defined by the organization. The following are traits of
informal nurse leaders identified by the nurse managers:
• expert nurses who want to share their knowledge;
• nurses whose names are often mentioned to lead
teams or volunteer;

• recognized leaders amongst their peers – staff gen-
erally migrate towards them;
M. Downey et al.
518 ª 2011 The Authors. Journal compilation ª 2011 Blackwell
Publishing Ltd, Journal of Nursing Management, 19, 517–521
• nurses who elevate the whole team – �Pulls everyone
together�; and
• nurses who have credibility and good track records
with both peers and management – the high per-
formers.
These factors and attributes align with (Smart 2005)
criteria for identifying informal leaders.
How informal leaders stand out amongst their
peers

The nurse managers interviewed for the present in-
vestigation stated that nurses who are informal leaders
have a strong work ethic (Grabowski & Logan 2009).
These nurses rarely have attendance problems, are
committed to patients, have integrity and always look
at the unit as a whole. One nurse leader stated that
informal nurse leaders have a sense of the �heartbeat of
the unit� and take an interest in making it better. These
leaders are strategic thinkers constantly absorbing and
analysing information and helping the team make better
decisions (Rath & Conchie 2008). With that broad
viewpoint, they can easily spot a coworker needing help
and are willing to help resolve the situation (Grabowski
& Logan 2009).

How informal leaders lead
Informal nurse leaders have varying forms of power.
Webster�s Dictionary (2009) defines power as the ability
to do, act; strength; having great influence. In physics,
power is defined as the potential or capacity for action,
a mobilizing force that overcomes resisting forces. In
human behaviour, power is the underlying force of all
social exchange (Bass 1990). In health care organiza-
tions, as in other organizations, power can be seen as
the ability to take actions and initiate interactions. It is
the capacity to ensure the outcomes one wishes and to
prevent those one does not desire.
Nurse managers and leaders might take a moment

and consider their own unit or organization. They
might think of a nurse who has not been officially
vested with formal status, but has attained a position of
power and influence, is able to mobilize the people
around them to act even though they have not been
officially designated as leaders. Seek the nurse who is
adept at using his or her influence to establish team
norms and values, and coordinate group efforts. A
nurse with these qualities is the informal leader. Their
power and influence is based on being effective com-
municators, building and sustaining strong relation-
ships, and always having a good �read� on how the
organization works (Smart 2010).

More qualities found in informal nurse leaders
Informal leaders want to be involved in discussions and
in shaping the direction of the unit or organization.
They are seen as standing up, speaking out, actively
listening and creating a safe comfortable environment
for others. These nurses are the leaders of the informal
and social networks. Informal networks are especially
important in knowledge-intensive sectors where people
use personal relationships to find information to do
their jobs (Cross et al. 2002).
The nurse managers stated that they hold informal
leaders in high regard because, when they consult with

them or make a request, the nurse manager is confident
the INL will follow through with the task at hand. Staff
and peers also gravitate towards informal leaders as
non-management because they are knowledgeable,
exude confidence and are trustworthy (Grabowski &
Logan 2009). Informal leaders are always willing to
help and are generally friendly and open allowing peers
to confide in them. INLs lead through relationship
building which is the essential glue that holds a team
together (Rath & Conchie 2008). For example, if a staff
nurse is new on the patient care unit and has a question,
the new nurses tend to feel more comfortable
approaching the nurse who is open and willing to share

information for the answer (Grabowski & Logan
2009).
How informal leaders view themselves
Informal leaders do not view themselves as special or
even as leaders necessarily. They think of themselves as
nurses doing their job. They come to work because it is
their �calling�. They have a sense of �ownership of the
unit� and they feel responsible for outcomes of patient
care (Grabowski & Logan 2009). Smart (2005) found
that a trademark of an informal leader is a sense of
humility. They are humble and do not �blow their own
horn� – trying to take credit; they simply focus on get-
ting the job done.
Informal leaders may accept acknowledgement or

rewards for their accomplishments; however, many
oppose any formal title or visible recognition. While
they often get recognition for their service that is not the
objective of serving. Their giving and service is what
they contribute rather than what they are receiving
(Sanborn 2006). Informal leaders feel strongly that a
Informal leaders
519
formal title would change the dynamics of how they
operate. A title might inhibit their ability to work qui-
etly behind the scenes and could impact their ability to

create a trusting environment.
How to support informal leaders
Support of INLs begins with understanding how they
approach their professional and organizational role. For
example, when informal nurse leaders learn about a
change in the organization they mobilize resources and
can help integrate the change and enlist the support
of the staff. Nurse managers can capitalize on this
behaviour by remembering that these nurses are in the
trenches, they have the pulse of the unit, have a network
of resources and are privy to information about which
the manager may not know. However, it is important to

avoid asking them to betray confidences. One of char-
acteristics of the informal leader is their ability to create
a safe environment for others (Smart 2010).
The current economic situation is creating an envi-
ronment where we manage and live on tight schedules
and tighter budgets. Time is the biggest challenge for
nurses within the context of delivery of effective patient
care. Bedside nursing takes nearly 100% of nurses� time
and energy. One of the top characteristics identified in
nurse satisfaction studies is having good nursing lead-
ership (Chambers & Mazzei 2008). Because the infor-
mal leader is fully committed to both the patient and the
unit they are often asked to work extra. Managers

should be mindful not to overuse their informal leaders.
To prevent burnout, managers should carefully choose
projects for their informal leaders [American Associa-
tion of Critical-Care Nurses (AACN) (2009)].
Nurse managers have the ability to assist informal
leaders in creating a positive and motivating environ-
ment. This can be done by encouragement and support
to create informal task forces to look at problematic
issues; give them opportunities to show how they help
solve current problems. Engaging nurses with diverse
backgrounds creates synergy and a greater commitment
to goals (Tornabeni & Miller 2008). Motivate the INLs
to get excited about the issues at hand as they are crea-

tive thinkers, and also look at creating a more formalized
way to tap into their knowledge and willingness to serve.
In instances of complaints regarding staff–patient-
relationships, low morale in nursing units or patient-
care complaints, nurse managers can leverage the
activist which is a vital quality of informal leaders.
Remember, informal leaders are typically your advo-
cates and are vested in the success of the unit. Their
power and influence is translated into nurse leaders who
are cheerleaders, motivators and problem solvers of the
unit (Grabowski & Logan 2009).
Informal leaders need to know that their positive

attitude and creative contributions are of great value to
you and the unit. Let them know that they are a moti-
vating force in the unit and that their efforts are making
a difference. Simple day-to-day recognition efforts can
be one of the most highly valued forms of rewarding
your nurses (Chambers & Mazzei 2008). Retreats or
gift cards may be simple means of encouragement.
After discovering the INL, the nurse managers and
leaders may find the best means to support the INL is
through mentorship. Mentoring the INL begins by
understanding the qualities discussed previously. For-
mal or informal mentorship programmes might be
developed to encourage the INL to continue their role.

Benefits of informal leaders to health care
management
The benefits of informal leaders to formal leaders and
organizations are numerous. Giving staff the freedom to
innovate and learn from their mistakes is at the heart of
good healthcare services (Clark 2008). Informal nurse
leaders have an impact on the quality of services as well
as the level of patient and staff satisfaction (Domm
et al. 2007). They influence the culture through their
overall enthusiastic involvement, freely sharing their
knowledge and expertise, team orientation and genuine
caring approach towards patients, staff.
As one nurse manager stated, managing informal

leader nurses is �painless� because they complete what-
ever is asked of them. Informal leaders are high per-
formers who are experts at doing more with less,
effectively using limited resources to their maximum
(Smart 2010). Because they always keep the broader
picture of the unit in mind, they can usually anticipate
the needs of other staff, physicians and patients. Infor-
mal leader nurses tend to feel a strong sense of owner-
ship and responsibility for the outcomes of the unit.
Most notably, they embrace the profession of nursing
(Grabowski & Logan 2009).
Conclusion
�Informal leadership is about heart�

Informal leaders are an essential component to meet the
current challenges of today�s health care environment. In
discussing nurses as informal leaders we have identified
who they are, the roles they play, how they impact the unit
and how they shape the organization. Collaboration, trust
M. Downey et al.
520 ª 2011 The Authors. Journal compilation ª 2011 Blackwell
and a high level of management support would definitely
contribute to nurses abilities to exercise informal lead-
ership (Resha 2006). Informal nurse leaders are an un-
derutilized asset in health care. These nurses can be

developed and empowered to impact unit performance,
efficiency and culture in a positive manner. When prop-
erly mentored, nurse leaders will find the informal nurse
leader is truly a �hidden treasure�.
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Informal leaders

521
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articles for individual use.
T
he business of health care is more
demanding than ever, with concerns
about payment reform and govern-
ment incentive programs that impose
penalties for non-participation on top of

the normal stresses associated with run-
ning a medical practice.
You have likely asked yourself within
the last year if you should consider adopt-
ing or upgrading your healthcare informa-
tion technology and taking part in these
incentive programs. Most physicians I talk
with would like to embrace the benefits this
technology allows but are stretched for re-
sources to dedicate to the task of under-
standing all the regulations and guidelines,
not to mention finding the time to under-
take this project.
There is a lot of money to be gained
from participating in EHR incentive pro-
grams through the Center of Medicare and
Medicaid (CMS). It is difficult and unwise
to advise anyone to completely discount the
potential of leaving that amount of money
on the table. Practices should also consider
whether the penalties associated with non-
participation are too large to ignore. If after
weighing the pros and cons you decide to

proceed, then now is the time to turn your
attention from the financial motivations
back to the clinical improvements you wish
to accomplish with the adoption of an EHR.
Before choosing a software solution
that will have such a large impact on the
culture and workflow of your practice,
there should be clear goals set that will de-
fine at the end of the process whether the
implementation was a success. This is the
one step that is physician- and practice-spe-
cific; no one else can define those for you.
It is best to use a team approach with at
least one physician taking the lead.
Make sure your team represents all
areas of your practice, such as nurs-
ing, medical records, administra-
tion, billing, registration, in-house
lab, etc. Potential goals you might set
for your practice could include cut-
ting patient phone call volume by 30
percent with the implementation of
ePrescribing, web-based appoint-

ment scheduling, nurse triage ques-
tions and patient educational
materials. You may also wish to de-
fine the clinical areas you want to
target for quality improvements,
such as patient reminders for blood
level monitoring or yearly preventive
testing. Whatever the goals defined
for your practice, once they have
been identified, that criteria will be
the driver for all your decisions
about product selection.
CHOOSING YOUR SYSTEM
Technology solutions are diverse and there
is no single solution that would meet the
requirements and preferences of all med-
ical practices. There are obvious places to
start your selection search, such as the Cer-
tified Health IT Products List (CHPL),
which includes all EHR systems that have
met federal criteria for the incentive pro-
gram (not every EHR system is eligible).
However, with more than 600 (and grow-
ing) products for ambulatory providers,

the CHPL list can be daunting. The qualifi-
cations for inclusion are strictly based on
functionality and this list does nothing to
rank or rate usability.
Knowing which EHRs are certified is a
start but which of those 600 products is the
easiest to use and the best fit for your prac-
tice? Which ones have the right functional-
ity to meet the goals you have defined?
Which best meet your physicians’ needs for
usability and documentation? Which of
them have the right contract terms and
meet requirements for your patient care as
well as your business needs? Where can
practices go to get expert direction and
help on choosing the right system?
THE TMA CAN HELP
Since January, the TMA has added new re-
sources in eHealth Services to help mem-
bers receive updates, clarification on
government programs, and a forum to have
their questions about health information

EHR Adoption:
Help is Here for Your
Decision-Making Process
By Angie Madden, CHC, CAPM
35Tennessee Medicine + www.tnmed.org + OCTOBER 2011
SPECIAL FEATURES
(Continued on page 37)
www.tnmed.org/vsp
maries sent by PCPs to specialists with a re-
ferral, consultation summaries sent by a
specialist back to the PCP – utilizing the
data standards identified and recom-
mended by the workgroups of the S&I
Framework initiative.
CHALLENGING TIMELINES
The timelines of Meaningful Use have

proven to be very challenging. There have
been delays in vendors testing their certi-
fied versions and releasing them to cus-
tomers. Even some practices and hospitals
that were established on EMRs have not
been able to implement the certified ver-
sion of their EMR and thus begin the re-
porting period for Meaningful Use. As a
result, the HIT Policy Committee an-
nounced in June that it will likely recom-
mend to CMS a staggered timeline that
would allow those eligible providers and
eligible hospitals that attest to Stage I Mean-
ingful Use in 2011 to move on to Stage II in
2013. But those providers and hospitals
that do not begin their first year until 2013
or 2014 would still be able to receive in-
centives in those years for meeting the cri-
teria of Stage I. Under the currently
published rule, providers and hospitals not
starting until 2013 must meet the (not yet
published) criteria for Stage II.
Regardless of any Meaningful Use time-

lines, the availability of essential informa-
tion about at patient in a timely manner,
i.e., at the time the patient is present, with
these transitions of care could reduce hos-
pital readmissions, avoid adverse medica-
tion events, avoid repeating diagnostic
studies, and provide patients and families
with information needed for them to par-
ticipate in care and be involved in their
own health.
THE ULTIMATE VALUE
Dramatic quality improvement in the care
of priority chronic diseases, such as dia-
betes and heart failure, in closed systems
with EMRs like the Veterans Administration
hospital system and Kaiser Permanente
have demonstrated the value of having clin-
ical information in structured (standard-
ized) format; this is one of the main driving
forces behind efforts to enable information
exchange that would make such improve-
ments also possible in the diverse systems
that exist across most of our country. To

match the quality improvements achieved
in closed healthcare systems requires in-
teroperable data exchange, which is the
aim of the S&I Framework initiative. If the
same double digit disparities in safety and
adverse events we see in health care existed
in another realm – let’s say the airline in-
dustry – can you imagine what the public
response would be? +
Dr. Leftwich is the chief medical informat-
ics officer for the State of Tennessee’s Office
of eHealth Initiatives. Contact him at 615-
507-6465 or [email protected]
SPECIAL FEATURES
technology answered. The newest element
of the TMA’s eHealth Services Division is
the Vendor Standards Program (VSP). This
program offers a list of vetted vendors who
have agreed to the TMA’s special terms on
best practices in training and implementa-
tion, safeguards in contracting language to
protect physicians, and a TMA member

cost reduction in their base fee. For physi-
cians stretched for resources, this is a ben-
efit of their membership and an added level
of confidence as they navigate the over-
whelming path of EHR adoption.
Vendors who have joined the VSP in-
clude Allscripts, NextGen and Sage. All of
them meet terms and conditions and offer
a client server
model as well
as a web-based
subscr ip t ion
product, so
there are ap-
p r o p r i a t e
choices for any
size practice on
any budget.
If you need help and direction on your EHR
journey, please contact the TMA’s eHealth
Services Division. We can answer questions
and offer assistance with healthcare tech-

nology adoption, incentive programs and
EHR selection, as well as any other eHealth
questions. Please visit the TMA website for
all your eHealth resource needs at
www.tnmed.org/ehealth. +
Ms. Madden is director of the TMA’s new
eHealth division. Formerly with the state
Office of eHealth Initiatives, she has a
background in medical practice admin-
istration, EHR consulting and imple-
mentation. Contact her at
800-659-1862 or
[email protected]
Join us for our webinar “A Case for EHR”
to learn more about EHR adoption
and our VSP program.
Wednesday, October 26
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EHR ADOPTION: HELP IS HERE FOR YOUR DECISION-
MAKING PROCESS
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RESEARCH
British Journal of Community Nursing Vol 15, No 12 611
Decision making within a

community provider organization
Ingela Berggren and Eric Carlstrom
Ingela Berggren, Senior Lecturer, Eric Carlstrom, Assistant
Professor, Department of Nursing, Health and Culture,
University
West, Division of Nursing, Trollhättan Email: [email protected]
Recent changes in health care with an increasing number of
patients cared for outside of institutions have led to more nurses
being employed in com-
munity health care.
Sweden has a health-care system managed by the county
councils, i.e. primary care and hospitals, while the com-
munities provide home care. All health care, with a few rare
exceptions, is publicly financed by taxes, which explains why
health care is so strongly affected by economic crises. This
situation coincides with an increase in the number of older
people and means a shortage of beds in nursing homes and
sheltered accommodation (Hellström and Hallberg, 2001).
Working mainly alone, community nurses can experi-
ence considerable pressure with regard to decision making,
whether they take sole responsibility or involve the patient
and/or their families (Berggren, 2005). This study focuses
on community nurses’ experiences with regard to their

decision-making opportunities.
Community care versus the
community provider organization
The focal point of community care is the patient’s needs and
what can be done to satisfy them (James, 1992; Lewis and
Timby, 1993). Care has been defined as intimate, mental and
physical attention given to a recipient (James, 1992). Sparbel
and Anderson (2000) stressed that the nurse’s goal is to person-
alize care to meet the patient’s changing needs during an ill-
ness. The nurse also strives to achieve continuity for the patient
from hospital to community or self-care (Haggerty et al, 2003).
The management imperatives in community health care
focus on resources and efficiency (Henkel, 1991). Hannigan
(1998) described managers influenced by New Public
Management (NPM) as more ‘free to manage’ as well as con-
cerned about efficiency and outcomes. The language of eco-
nomics (Rombach, 2005), has a major impact on health care.
Nowadays it is used in contexts where terms such as cost
and utility were never previously mentioned. One example is
Becker’s (1993) report on correlations from a purely market
perspective, illustrated by means of mathematical formulae.
The language of economics is now dominant and viewed as
value neutral (Browne, 2001). Management imperatives are

also characterized by models aimed at exercising control and
creating predictability (Granovetter, 1985). This has affected
care, making it the product of increased focus on control and
economic follow-ups (Stewart and Walsh, 1992).
There are clear differences between the cultures of care
and management. The manager has, over time, gained
increasing influence (Harrison and Pelletier, 2000). By
analogy with the development that has taken place in hos-
pitals, the different actors have been compared to a family.
James (1992) described how the physician has taken a step
back from the father role and become like an uncle or aunt,
while the manager has assumed the father role (Needham,
1997). Although nurses are pulled into managerialism,
Carney (2006) revealed that they have developed their own
ways of reinterpreting management intentions, in that they
tend to focus on local concerns rather than the broader
organizational strategy (Harrison and Miller, 1999).
Integration of community health
care and the provider organization
There is an increasing demand for nurses to integrate
economic control and translate organizational perspec-
tives into care (Spitzer, 1987; James, 1992). This has
contributed to changes in the nurse’s role (Ewens, 2003).

Nurses working in accordance with two dissonant imper-
AbstrACt
Aim: To explore community nurses’ experiences of decision
making within
the community provider organization.
Background: Recent changes in health care with an increasing
number
of patients being cared for outside of institutions can put
considerable
pressure on the nurse with respect to decision making.
Methods: In-depth interviews were performed with 6
registered
nurses in two communities. The interviews were analysed by
means of
phenomenological hermeneutics.
Results: The community nurses’ experiences of decision
making were
interpreted as spiders or octopuses, consultants and
troubleshooters. The
subthemes were; networking and structuring, responsibility,
availability and
knowledge, assessment power, information selection, avoiding
rules and
bypassing managers. In accordance with hermeneutical

phenomenology,
the findings were discussed and explained with reference to
Ofstad’s
philosophy of freedom to make decisions.
Conclusion: In their decision making, community nurses are
committed to
finding administrative solutions that satisfy patient needs.
KEY WOrDs
Community nursing care w Decision-making w Integration w
Management w Phenomenological hermeneutics
RESEARCH
612 British Journal of Community Nursing Vol 15, No 12
atives experience role confusion (Cronqvist et al, 2006), a
situation described by James (1992) as follows:
‘Tension between organisational priorities and
organising individual patient care may appear
insurmountable even when staff actively seek to
give good patient care.’ (p. 495)

One of the difficulties for nurses is that care and organi-
zational activities take place at different levels. The former
is practised at actor level and the latter at system level.
Within care, the individual’s experiences are important
and the unique is in focus. The imperatives of care consist
of subtle phenomena that require competency, experience
and sometimes intuition, which are difficult to register and
quantify (McCutcheon and Pincombe, 2001). In contrast,
management philosophy generalizes the patient’s experi-
ences. The imperatives are based on quantitative measure-
ments. Care, therefore, tends to be reduced to bandages,
catheters, treatment and consultations (James, 1992). High
quality care is, however, not easy to measure because its
parameters are subtle and difficult to observe.
Increasing resources have been dedicated to control,
measurement and data reporting (Wells, 1995). The focus
has shifted from the qualities required when encounter-
ing each individual patient to the handling of calculable
data based on clinical, functional and financial parameters
(Harvey, 2004). The nurse is therefore not always free to
make decisions and provide the care dictated by his or
her sense of responsibility (Berggren, 2005; Bégat, 2006).
In particular, nurses employed in hospitals who hold a

middle management position have been called ‘the jam in
the sandwich’, because they are close to the patients. They
have to cope with the demands of the patients as well
as the performance criteria imposed upon them by the
business-planning framework (Currie and Brown, 2003).
Carney (2004) emphasized that the caring approach tends
to dominate among professionals in health-care settings,
which has contributed to strategic management difficulties.
The majority of studies that describe the interface
between care and management imperatives are from hos-
pital settings and deal with the influence of managerial
ambitions on physicians (James, 1992; Kurunmäki, 2004;
Brorström and Nilsson, 2008).
Decision making
Unlike nurses working in a hospital, community nurses
care for patients in their own home, sometimes alone
without the support of colleagues or other profession-
als. They have to take decisions on a daily basis, often
alone and unsupported (Berggren, 2005). In the area of
community nursing and decision making, there are few
studies about, for example, wound care (Hallett, 2000),
team work (Cook et al, 2001), risks in community
practice (Alaszewski, 2006), pressure ulcer prevention

(Papanikolaou et al, 2007) and nurse–patient interaction
(Millard et al, 2006).
Furthermore, Goodman et al (2010), who conducted a
review aimed at finding evidence for how to support the
final phase of end-of-life care for older people with demen-
tia in community health care, found that there is a need to
investigate interventions and outcome measures. However,
some studies focus on community health nurses in rela-
tion to palliative home care (Karlsson et al, 2010; Carlsson
and Berggren, 2010). According to Markham and Carney
(2008), there is limited research on quality nursing care in
the community. The authors examined factors impacting
on quality nursing care: role change; components of quality
nursing care; barriers to quality nursing care; and factors
facilitating the delivery of quality nursing care. The findings
revealed a need for education and knowledge.
Despite the fact that patients are increasingly cared for in
their own homes and that more and more nurses are employed
as community health nurses, little research from the nurses’
perspective has been conducted and it is therefore important
to obtain greater knowledge of this area. The present study
focuses on community nurses’ decision-making processes.

the aim
The aim was to illuminate community nurses’ experiences
of decision making within the community health-care
organization.
Method
Participants
The study comprised six convenienced sampled community
nurses from two urban communities in western Sweden, all
of whom were women aged between 45-62 years. Each com-
munity nurse had considerable professional experience, with a
mean age of 37.6 years. An inductive approach was employed in
order to enhance knowledge of community nurses’ experiences
with a focus on decision making in relation to high quality care.
Ethical considerations
The study was discussed at the ethics committee of the
university and the Helsinki guidelines were adhered to
(World Medical Association, 2008). The nursing managers
in the two communities approved the study. The com-
munity nurses were invited to participate and those who
accepted gave their informed consent. They were informed
that participation was voluntary. Confidentiality was guar-
anteed and they were free to withdraw from the project at

any time without any negative consequences.
Data collection
In-depth interviews (Kvale and Brinkman, 2009) in which
direct questions were posed were conducted with the
6 community nurses. The interviews were conducted by
the main author and lasted for approximately one hour.
They were audio-taped and transcribed verbatim.
Data analysis
A qualitative method inspired by Ricoeur’s (1976) phe-
nomenological hermeneutics was used. The method was
RESEARCH
table 1. themes and sub-themes
Themes Spiders or
Octopuses
Consultants Trouble-shooters

Sub-
themes
Networking
Structuring
Responsibility
Availability
Knowledge
Assessment power
Information selection
Avoiding rules
Bypassing managers
developed by Lindseth and Norberg (2004) and builds
on people’s statements about their lived experiences
and comprises understanding, interpretation, description
and thematic analysis of qualitative data. The method

is a combination of phenomenological narratives and a
hermeneutical understanding of the deep meaning of
these experiences (Lindseth and Norberg, 2004).
The phenomenological description attempts to cor-
rectly describe people’s lived experiences so that they can
acknowledge the description as genuine. To attain this goal,
it is necessary that the authors are aware of and willing
to abstain from their own pre-understanding and preju-
dices. The phenomenological-hermeneutical interpretation
involves a moving back and forth in the text. The interpreter
moves between the text as a whole and its parts in a logical,
hermeneutical circle. The fusion or merging of the horizon
of the meaning of the text, i.e. the participants’ lived expe-
riences, becomes accessible by means of interpretation. It
means that something new emerges from the data.
The interpretation of the text by means of phenom-
enological hermeneutics involved three phases, which
together constitute the hermeneutical circle (Ricoeur,
1976). In the first phase, the text was read in order to gain
an immediate (naive) understanding of the whole, always
bearing the aim of the study in mind. The authors read the
narratives on several occasions before making a preliminary
interpretation of the text as a whole. In the second phase,

the text was divided into meaning units, which were later
condensed, abstracted and divided according to the emerg-
ing themes and sub-themes. At this stage of the analysis,
it is important to remain close to the text and compare
it with the naive interpretation. The third and final phase
consists of a comprehensive understanding, which means
interpreting the text as a whole in the light of the naive
understanding and themes (Lindseth and Norberg, 2004).
rigor
The validity of the findings was based on the structural
analysis, where patterns in the text were identified, which
explained and either validated or invalidated the inter-
pretation made on the basis of the naive understanding.
The authors read the transcribed interviews and discussed
the sub-themes and themes until consensus was reached
about the comprehensive understanding. Quotations
were used in the presentation of the findings in order to
RESEARCH

increase trustworthiness. The study has a thread from the
aim, the theoretical conceptual framework and methodo-
logical framework to the interpretation.
results
Naive understanding
The naive understanding demonstrated that community
nurses’ decision making focused on what was best for
the patient and his or her relatives, for example when the
organization raised barriers. In various ways they managed
to ensure that the patients’ wishes were met, something
they reported often depended on the other health profes-
sionals allocated to the patient. The level of knowledge
varied among the other staff, which had an impact on the
community nurses’ decisions. The nurses also perceived
that they had a large group of people including the patient,
his or her relatives, health professionals, colleagues and
managers as well as a great number of duties to deal with,
which in turn meant a huge number of decisions. They
viewed the community provider organization as both a
hindrance and an opportunity for the decision making.
the structural analysis
In the structural analysis the transcribed interviews, from

the 6 community nurses, were viewed as a whole and three
themes emerged from the data; ‘Spiders or Octopuses’ with
two sub-themes: networking and structuring; ‘Consultants’
with three sub-themes: responsibility, availability and
knowledge; and ‘Troubleshooters’, which had four sub-
themes: power to carry out assessments, selection of infor-
mation, avoiding rules and by-passing managers. These
themes illuminate the community nurse’s experiences of
decision making within the community provider organiza-
tion (Table 1).
spiders or Octopuses
The 6 registered community nurses’ general work assign-
ments were planning, prioritizing, and discussing together
with the patient, relatives, other caregivers and staff members
to determine and make decisions according to the patient’s
care requirement. The 6 nurses in this study described their
own role in the organization in a similar way. They all had a
large network of contacts. One nurse described it as follows:
‘Like a spider, I have contacts in all directions…
I don’t know if my name is at the top of some-
body’s list. I receive a lot of phone calls…like a
spider in a web.’

It was the community nurses’ duty to report to col-
leagues from the different work groups with which they
were involved. One nurse described her role in the health
care organization in this way:
‘Like an octopus with all its arms in different
directions, I structure care around the patient.’
The patients were scattered all over the community. Each
community nurse had her own speciality, thus the patients
requiring her care were located in different districts. This
meant that the specialist, i.e. the community nurse, had to
train and supervise different groups of personnel, which
included assistant nurses and care assistants working in the
various districts. When the personnel had difficulty provid-
ing care, they contacted the registered nurses for advice.
A culture of mutual respect and a system that values both forms
of knowledge and expertise are important
p
ee
p

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/i
St
o
ck
p
h
o
to
RESEARCH
by the county council. They were responsible for patient
assessments and reported to the physicians employed by the
county council, who they provided with selected informa-
tion in order to distribute resources that they considered
necessary for the care. The staff managers were aware of this
behaviour and the extra costs it generated, but had no tools
with which to control it.

The community nurses also found strategies to avoid rules
and policies that diminished their decision-making capacity.
They had, for example, to adhere to rules such as not being
allowed to take blood samples in the patient’s home because
the community was not allocated resources for such serv-
ices. Instead, the patient had to visit the local clinic for tests.
However, the community nurses managed to arrange for
community care personnel to visit disabled patients in their
homes and take blood samples. They simply disregarded
resource allocation and organizational constraints.
The community nurses also found strategies for disregard-
ing policies within their own area of work (the community).
Normally the managers had the power to approve nursing
home care or additional personnel for a seriously ill patient.
However, the managers only worked during office hours,
thus the community nurses could make decisions in the
evenings and at weekends when the manager was off duty.
This was a solution when community nurses and managers
had different opinions as to what was best for the patient.
‘I had to work out a package that would function
when I had left.’

Issues arose when patients needed additional care from the
community nurse. One example of this was when a commu-
nity nurse reported that a patient in palliative care had only
one relative who could assist the care staff. The manager’s
response was to ask how long it would be until the patient
passed away. It had become a financial issue. The community
nurses claimed that the managers did not speak the same
‘language’ as they did. The managers planned and organized
in order to save resources, while the community nurses tried
to bypass the manager and find staff to support the patient.
Such arrangements were seldom reported to the manager.
Comprehensive understanding
The results highlighted by Ofstad (1961) who explained how
decisions are made on a continuum between low and high-
integrated decisions. Low-integrated decisions do not require
special consideration and are not based on intrinsic properties
of the decision maker’s personality. On the other hand, high-
integrated decisions are based on individual ethical value
systems, arguments and intrinsic properties of an individual’s
personality (Ofstad, 1961). In the course of their duties,
nurses make both low and high-integrated decisions. The lat-
ter highlight the individual nurse’s personal value system. The
community nurses in this study focused on high-integrated
decisions, as they had a bearing on their own values.

Ofstad (1961) drew attention to the line between
actor and system when describing the factors that influ-
The community nurses were considered specialists and were
also responsible for geographic districts, which complicated
the coordination among nurses and staff. The staff often con-
tacted the most available nurse rather than the nurse in charge,
which meant that the nurses’ knowledge of each patient was
fragmented. They networked and structured patients, staff and
colleagues in order to ensure high quality care.
Consultants
The 6 community nurses’ primary responsibility was to
care for their patients, but they also had duties, such as
interacting with other staff members. They considered
themselves consultants, because other staff members, rela-
tives of the patient and sometimes the patient requested
their assistance in every conceivable situation. They were
expected to make judgments about the patient’s condition.
The knowledge of the patient’s and relatives’ wishes regard-
ing care had to be considered by the nurses and staff in order
for the patient to receive appropriate attention. The work-
group personnel in the patient’s locality did not always have

sufficient knowledge to provide appropriate care, which led
to complications. Competent personnel had to be brought in
from other workgroups and work schedules modified.
The community nurses, however, were unable to make
decisions regarding care personnel. They were restrained
by their consultant role. Ideas about new procedures,
including those associated with the patient’s medical safe-
ty, had to be presented at meetings with the supervisors.
Decisions were often taken after a democratic vote. This
system had even been applied to so-called incidents, i.e.
situations where the patient’s medical safety was at risk.
The staff manager was not trained in care work and could
therefore not offer the support expected by the subordi-
nates. Negative feelings sometimes arose when the nurses
expressed dissatisfaction over the staff manager’s inability to
understand. The community nurses’ and manager’s conflict-
ing points of view could lead to cooperation difficulties.
‘There can sometimes be a clash between what
we nurses think is important and the home nurs-
ing manager’s views. The economic restrictions
determine who should be allocated most money.’

troubleshooters
The 6 community nurses felt that health-care organizational
policies and rules hindered decision making. One example
was the care planning for an elderly patient, who was seri-
ously ill because of poor circulation in the legs which had
the potential of leading to amputation. The care planning
conference was supposed to decide whether the patient
could continue to live at home. The community nurses
received instructions from the care supervisor not to consid-
er any medical aspects in connection with the care planning.
However, the community nurses had the authority to make
decisions in their daily work with patients. The decisions
were made both within the community where the nurse
was employed and outside, i.e. the primary care provided
A culture of mutual respect and a system that values both forms
of knowledge and expertise are important
RESEARCH
knowledge was at risk of being neglected and thereby their

decision-making abilities were restrained.
However, the community nurses perceived the organiza-
tion not only as a hindrance, but also as a potential asset.
They did not support the organizational focus of the
supervisory and administrative personnel. Instead, they
familiarized themselves with the profile of the organization
in order to find loop-holes in the policies and procedures
for the benefit of the patient. They sometimes waited for
the staff manager to go off duty in order to find a place
for the patient. When a conflict arose between the nurses’
goal to personalize the community care and the manager’s
ambition to save resources, the community nurses tried
various ways of ensuring adequate care.
When there was a shortage of qualified personnel, the
community nurses assisted with scheduling and found
exceptional administrative solutions. Their decision mak-
ing and involvement helped the organization to better
serve the needs of its patients and meant that they did not
exhibit the role confusion described by Cronqvist et al
(2006). Instead, they had a clear understanding of organi-
zational structures.
The community nurses used what Ofstad (1961) labelled

‘the use of attention’ in their contact with the patient and
the patient’s family. It was employed in the course of the
daily meetings with the patient, but also by means of the
information provided by the care personnel. The knowl-
edge acquired was coupled with their existing knowledge
of the organization, which corresponds to Ofstad’s (1961)
term ‘environment’. If the community nurses were pre-
vented from delivering high quality care, they tried to
make decisions which influenced the organization to
function in such a way as to benefit the individual patient
by manipulating organizational structures in order to gain
increased freedom to act.
Limitations
The study has limitations owing to the fact that the
sample comprised only 6 informants. However, despite
the low number of informants, the data contained rich
information about the phenomenon as the qualitative
interviews allowed the informants’ perceptions of their
life world. The findings may be transferable to com-
munity nurses who work in other communities, given
that they are in a similar position, irrespective of the care
environment. While the results of a qualitative study can-
not be generalised, it can be assumed that similar findings
would emerge from interviews with other community

health nurses in different communities.
Conclusion and relevance
to clinical practice
The community provider organization with management
imperatives can have a negative impact on community
nurses’ decision making and thereby on community nurs-
ing care despite the fact that to a large degree the care
takes place in the patient’s home on his or her own terms.
ence the decision-making process, three of which are of
importance in this context: ‘The use of attention’, ‘Efforts
to decide’ and ‘Environment’. The first two relate to the
nurse’s desire to support the patient and create a relation-
ship. ‘The use of attention’ concerns the nurse’s ability to
understand the patient’s resources. When these are lack-
ing, compensating strategies are required. Ofstad (1961)
argued that while a person may be free to make decisions,
the same person can be prevented, either physically or
mentally, from acting freely (p. 202). An individual can
also be forced to carry out actions that conflict with
fundamental values, as was sometimes the case with
the nurses in this study (Ofstad, 1961). The informants
described themselves as spiders or octopuses, consultants
and troubleshooters when caring for the patient, as they

did not have the freedom to make high-integrated deci-
sions. When it came to actions, they perceived limitations
that prevented them from acting in a way that was ben-
eficial for the patient. How nurses make high integrated
decisions depends on their fundamental value system, the
use of attention, efforts to decide and the environment.
‘Efforts to decide’, in this context, involves the nurse’s
decision-making ability aimed at assisting the patient and
implies that a decision can be made. ‘Environment’ stems
from the organizational level and includes the ability to
make decisions that are essential for the patient. Thus a
causal relationship exists between ‘The use of attention’,
‘Efforts to decide’ and ‘Environment’. Attention gives
the nurses the opportunity to make decisions as long as
the necessary provisions exist within the organization.
Ofstad’s (1961) theory is therefore applicable whenever
nurses are responsible for decision making and when a
dilemma can arise due to, for example, conflicts between
care and organizational requirements.
Discussion
This study reveals that nurses in community health care
experienced weakened possibilities to decision making by
a lack of organizational focus on medical safety, compe-
tence, accessibility and distribution of resources. Further,

the community health care is limited by conflicts of
interest, internal organizational fragmentation and inter-
organizational differences. The community nurses priori-
tized caring and medical needs of the patients, whereas
managers prioritized organizational aspects.
The community nurses’ decision making was also lim-
ited by a demand for predictability, i.e. that all activities
should be planned. Another limitation was that the com-
munity nurses had managers who had no caring or medi-
cal training at all. This meant that the community nurses
had only limited ability to decision making according to
the patient’s caring and medical needs. This is similar to
Carlström’s (2005) description of how community nurses
are viewed as dealing with traditional community concerns
rather than health care. The result was, for example, that
they were expected to primarily perform social work and
only then health-care work, which meant that their special
RESEARCH

KEY POINts
w The study show that the community provider organization
with
management imperatives can have a negative impact on
community
nurses’ decision making.
w The community nurses perceived the organization not only as
a hindrance,
but also as a potential asset.
w The community nurses familiarized themselves with the
profile of the
organization in order to find loop-holes in the policies and
procedures for
the benefit of the patient.
w When a conflict arose between the nurses’ goal to personalize
the
community care and the manager’s ambition to save resources,
the
community nurses tried various ways of ensuring adequate care.
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tives of care as well as those of the health-care organiza-
tion in order to develop and render the latter more effi-
cient without lowering the quality of the former. It also
highlights the necessity of developing a culture of mutual
respect and a system that values both forms of knowledge
and expertise (Catalano et al, 2009). BJCN
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IB and EC were responsible for the study conception and
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IB performed the data collection. IB and EC performed the data
analysis, were responsible for the drafting of the manuscript and
made critical revisions to the paper for intellectual content.
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