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changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own
experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described
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With respect to any drug or pharmaceutical products identified,
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or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on
their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the
authors, contributors, or editors, assume any liability for any injury
and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the
material herein.

Previous editions copyrighted 2014, 2010, 2006, 2000, and 1996.

International Standard Book Number: 978-0-323-38966-2

Senior Content Strategist: Yvonne Alexopoulos

Senior Content Development Manager: Laurie Gower
Associate Content Development Specialist: Laurel Shea
Publishing Services Manager: Jeff Patterson
Book Production Specialist: Bill Drone
Designer: Amy Buxton

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Last digit is the print number: 9 8 7 6 5 4 3 2 1

9
Contributors
Jennifer Bellot, PhD, RN, MHSA, CNE, Associate Professor and
Director, DNP Program, Jefferson College of Nursing, Thomas
Jefferson University, Philadelphia, Pennsylvania

Jane M. Brokel, PhD, RN, Section Instructor, Online Nursing,

Simmons College, Adjunct Faculty, College of Nursing,
University of Iowa, President, NANDA International, Inc.,
Registered Nurse, Parish Nursing Cluster Parishes and Accurate
Home Care

Marie-Hélène Budworth, PhD, MS, BA, Associate Professor of

Human Resource Management, Director, School of Human
Resource Management, York University, Toronto, Ontario, Canada

Lynn Christensen, MSN, RN, Safety and Emergency

Management Officer, Inova Loudoun Hospital, Leesburg, Virginia

Sean P. Clarke, PhD, RN, FAAN, Professor and Associate Dean,

Undergraduate Program, Connell School of Nursing, Boston
College, Chestnut Hill, Massachusetts

Karen S. Cox, PD, RN, FACHE, FAAN, Executive Vice

President/Chief Operating Officer, V. Fred Burry, MD, and

10
Sandra Hobart Burry Chair in Nursing Advocacy and Leadership,
Children’s Mercy Hospital, Kansas City, Missouri

Kathleen B. Cox, PhD, RN, Associate Director, School of

Nursing, Radford University, Radford, Virginia

Laura Cullen, DNP, RN, FAAN, Evidence-Based Practice

Scientist, Office of Nursing Research, Evidence-Based Practice and
Quality, Department of Nursing Services and Patient Care,
University of Iowa Hospitals and Clinics, Iowa City, Iowa

Cindy J. Dawson, MSN, RN, CORLN, Director, Clinical

Functions Ambulatory Nursing, University of Iowa Hospitals and
Clinics, Iowa City, Iowa

Elizabeth T. Dugan, PhD, RN, MBA, MSN, NEA-BC, Chief

Nursing Officer, Inova Loudoun Hospital, Leesburg, Virginia

Michele Farrington, BSN, RN, CPHON, Clinical Healthcare

Research Associate, Office of Nursing Research, Evidence-Based
Practice and Quality and Ambulatory Nursing, University of Iowa
Hospitals and Clinics, Iowa City, Iowa

Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM,

CRP, Principal, EFS Supervision Strategies, LLC, Burke, Virginia

Betsy Frank, PhD, RN, ANEF, Professor Emerita, School of

Nursing, Indiana State University, Terre Haute, Indiana

Maryanne Garon, DNSc, RN, Professor and Nursing Leadership

Concentration Coordinator, California State University, Fullerton,
Fullerton, California

11
Gregory O. Ginn, BA, MEd, MBA, PhD, Adjunct Assistant
Professor, Embry-Riddle Aeronautical University–Worldwide,
Daytona Beach, Florida

Kirsten Hanrahan, DNP, ARNP, Nurse Scientist, Office of

Nursing Research, Evidence-Based Practice and Quality,
Department of Nursing and Patient Care Services, University of
Iowa Hospitals and Clinics, Iowa City, Iowa

Mary G. Harper, PhD, RN-BC, Director of Nursing Professional

Development, Association for Nursing Professional Development,
Flagler Beach, Florida

Farinaz Havaei, PhD, PhD Candidate, School of Nursing,

University of British Columbia, Vancouver, British Columbia,
Canada

L. Jean Henry, PhD, Associate Professor, Public

Health/Community Health Promotion, College of Education and
Health Professions, University of Arkansas, Fayetteville, Arkansas

Julie A. Holt, RN, MSN, CENP, Vice President, Patient

Services, Chief Nurse Executive, The Christ Hospital Health
Network, Cincinnati, Ohio

Cheryl Hoying, PhD, RN, NEA-BC, FACHE, FAAN, Senior Vice

President, Patient Services Division, Cincinnati Children’s Hospital
Medical Center, Associate Dean, College of Nursing, University
of Cincinnati, Cincinnati, Ohio

Lianne Jeffs, PhD, RN, FAAN, St. Michael’s Hospital Volunteer

12
Association Chair in Nursing Research, Scientist, Keenan
Research Centre of the Li Ka Shing Knowledge
Institute, Associate Professor, Lawrence Bloomberg Faculty of
Nursing and Institute of Health Policy Management and
Evaluation, University of Toronto, Toronto, Ontario, Canada

M. Lindell Joseph, PhD, RN, Associate Clinical Professor and

MSN/CNL Program Coordinator, College of Nursing, University of
Iowa, Iowa City, Iowa

Jayne Josephsen, EdD, MS, RN, CHPN, Associate Professor,

School of Nursing, Boise State University, Boise, Idaho

Susan R. Lacey, PhD, RN, FAAN, Professor, College of Nursing,

Medical University of South Carolina, Charleston, South Carolina

Trudy A. Laffoon, MA, RN-BC, Nurse Manager, Pain

Management and Medicine Specialty Clinics, University of Iowa
Hospitals and Clinics, Iowa City, Iowa

Michael Soon Lee, DBA, MBA, BA, President, EthnoConnect®,

Member, National Speakers Association, Dublin, California

Maura MacPhee, PhD, RN, Associate Professor, School of

Nursing, Associate Director, Undergraduate Nursing Program,
University of British Columbia, Vancouver, British Columbia,
Canada

Lynn S. Muller, JD, RN, CCM, BA-HCM, Partner, Muller &

Muller, Attorneys at Law, Adjunct Professor, School of Nursing,
Saint Peter’s University, Englewood Cliffs, New Jersey

13
Nathan Neis, DNP, CPNP-AC, Nurse Practitioner, PICU/CICU
at Children’s Hospital of Wisconsin, Milwaukee, Wisconsin

Adrienne Olney, MS, Research Associate, Children’s Mercy

Hospitals and Clinics, Kansas City, Missouri

Anne Gallagher Peach, RN, MSN, NEA-BC, Partner, Future

Vision Group, Orlando, Florida

Luc R. Pelletier, MSN, APRN, PMHCNS-BC, FAAN, CPHQ,

FNAHQ, Senior Nursing Specialist, Sharp Mesa Vista
Hospital, Adjunct Professor, National University, San Diego,
California

Slimen Saliba, PhD, MBA, MA, BA, Senior Vice President of

Marketing, Adventist Health System–Florida Division, Orlando,
Florida

Teresa Kathleen Sparks, JD, MSN, BSN, RN, Faculty, MHCA

and BSN Programs, College of Health Sciences, University of
Arkansas, Fort Smith, Fort Smith, Arkansas

Abdullah S. Suhemat, BScN, MSN, Lawrence S. Bloomberg

Faculty of Nursing, University of Toronto, Toronto, Ontario,
Canada

Linda B. Talley, MS, BSN, RN, NE-BC, Vice President and Chief
Nursing Officer, Children’s National Health System, Washington,
DC

Diane H. Thorgrimson, MHSA, BS, Executive Director,

Workforce Planning, Special Projects, and Productivity for Patient

14
Services, Children’s National Health System, Washington, DC

Teresa M. Treiger, RN-BC, MA, CHCQM-CM/TOC,

CCM, Principal and Case Manager, Ascent Care Management,
LLC, Quincy, Massachusetts

Kathleen A. Vertino, DNP, PMHNP-BC, CARN-AP, Board-

Certified Nurse Practitioner, Psychiatry, Buffalo, New York

Carol A. Wong, PhD, RN, Associate Professor, Arthur Labatt

Family School of Nursing, Faculty of Health Sciences, Western
University, London, Ontario, Canada

15
Reviewers
Karen E. Alexander, PhD, RN, CNOR, Director, RN-BSN, and
Assistant Professor, Department of Clinical Health and Applied
Sciences—Nursing, University of Houston Clear Lake, Houston,
Texas
Barbara B. Blozen, EdD, MA, RN, BC, CNL, Associate Professor,
Department of Nursing, New Jersey City University, Jersey City,
New Jersey
Lori Jo Bork, PhD, RN, MS, BSN, CCRN, Professor of Nursing,
Department of Nursing, Dakota Wesleyan University, Mitchell,
South Dakota
Karen Brown-Fackler, RN, EdD, NEA-BC, CNL, CNE, Associate
Professor of Nursing, Department of Nursing, Saginaw Valley State
University, University Center, Michigan
Beverly Waller Dabney, PhD, RN, CCM, Associate Professor of
Nursing, Department of Nursing, Southwestern Adventist
University, Keene, Texas
Rebecca M. Davidson, PhD, MSN, RN, Instructor of Nursing,
Caylor School of Nursing, Lincoln Memorial University, Knoxville,
Tennessee
Richard C. Meeks, DNP, RN, COI, Assistant Professor, School of
Nursing, Middle Tennessee State University, Murfreesboro,
Tennessee
Barbara J. Pinekenstein, DNP, RN-BC, CPHIMS, Clinical
Professor, Richard E. Sinaiko Professor in Health Care Leadership,
University of Wisconsin, Madison, Madison, Wisconsin

16
Darlene M. Rogers, MSN, BS, RN-BC, Clinical Instructor, Georgia
Baptist College of Nursing, Mercer University, Atlanta, Georgia

17
Preface
Strong leadership and care management are imperatives for
nursing. Highlighted by a series of reports from the prestigious
Institute of Medicine (IOM; now called the National Academies of
Sciences, Engineering, and Medicine, Health and Medicine
Division)—most recently The Future of Nursing: Leading Change,
Advancing Health—it is clear that nurses matter to health care
delivery systems. Yet the United States is in the midst of a
continuing and projected nurse shortage. Strong nurse leaders and
managers are important for clients (and their safety), delivery
systems (and their viability), and payers (and their solvency).
Pressures remain to balance cost and quality considerations in a
complex, chaotic, and turbulent health care environment.
Although society’s need for excellent nursing care remains the
nurse’s constant underlying reason for existence, nursing is in
reality much more than that. Because nurses offer cost-effective
expertise in solving problems related to the coordination and
delivery of health care to individuals and populations in society,
they have become a crucial linchpin in health care delivery and are
highly valued. Nurses are well prepared to lead clinical change
strategies and effectively manage the coordination and integration
of interdisciplinary teams, population needs, and systems of care
across the continuum. This has been especially important following
implementation of the 2010 Patient Protection and Affordable Care
Act (ACA), and nurses are needed to address care coordination and
integration across the health care delivery system.
It can be argued that nursing is a unique profession in which the
primary focus is caring—giving and managing the care that clients
need. Thus nurses are both health care providers and health care

18
coordinators; that is, they have both clinical and managerial role
components. Beginning with the first edition of Leadership &
Nursing Care Management, it has been this text’s philosophy that
these two components can be discussed separately but in fact
overlap. Because all nurses are involved in coordinating client care,
leadership and management principles are a part of the core
competencies they need to function in a complex health care
environment.
The turbulent swirl of change in this country’s health care
industry has become a paradigm shift that has provided both
challenges and opportunities for nursing. Nurses need a stronger
background in nursing leadership and care management to be
prepared for contemporary and future nursing practice. As nurses
mature in advanced practice roles and as the health care delivery
system restructures, nurses will become increasingly pivotal to cost-
effective health care delivery. Research is bearing this out.
Leadership and management are crucial skills and abilities for
complex and integrated community and regional networks that
employ and deploy nurses to provide health care services to clients
and communities.
Today’s nurses are expected to be able to lead and manage care
across the health care continuum—a radically different approach to
nursing from what has been the norm for hospital staff nursing
practice. In all settings, including both nurse-run and
interdisciplinary clinics, nursing leadership and management are
complementary skills that add value to solid clinical care and
patient- and client-oriented practice. Thus there is an urgent need to
advance nurses’ knowledge and skills in leadership and
management. In addition, nurses who are expected to make and
implement day-to-day management decisions need to know how
these precepts can be practically applied to the organization and
delivery of nursing care in a way that conserves scarce resources,
reduces costs, and maintains or improves quality of care. This is the
emphasis on adding value, innovation, and prevention
interventions.
The primary modality for health care in the United States has
moved away from acute care hospitalization. As prevention,
wellness, and alternative sites for care delivery become more

19
important, nursing’s already rich experiential tradition of practice
in these settings is emerging. This text reflects this contemporary
trend by blending the hospital and nonhospital perspectives with
an eye toward systems leadership and management.

Purpose and audience

The intent of this text is to provide both a broad introduction to the
field and a synthesis of the knowledge base and skills related to
both nursing leadership and nursing care management. It is an
evidence-based blend of practice and theory that breaks new
ground by explaining the intersection of nursing care with leading
people and managing organizations and systems. It highlights the
evidence base for care management. It combines traditional
management perspectives and theory with contemporary health
care trends and issues and consistently integrates leadership and
management concepts. These concepts are illustrated and made
relevant by practice-based examples.
The impetus for writing this text comes from teaching both
undergraduate and graduate students in nursing leadership and
management and from perceiving the need for a comprehensive,
practice-based textbook that blends and integrates leadership and
management into an understandable and applicable whole.
Therefore the main goal of Leadership & Nursing Care Management
is twofold: (1) to clearly differentiate traditional leadership and
management perspectives and (2) to relate them in an integrated
way with contemporary nursing trends and practice applications.
This textbook is designed to serve the needs of nurses and nursing
students who seek a foundation in the principles of leading and
coordinating nursing services in relation to client care, peers,
superiors, and subordinates.

Organization and coverage

This sixth edition continues the format first used with the third
edition. The first two editions were Dr. Huber’s single-authored
texts. The edited book approach draws together the best thinking of

20
experts in the field—both nurses and non-nurses—to enrich and
deepen the presentation of core essential knowledge and skills.
Beginning with the first edition, a hallmark of Leadership & Nursing
Care Management has been its depth of coverage, its
comprehensiveness, and its strong evidence-based foundation. This
sixth edition continues the emphasis on explaining theory in an
easily understandable way to enhance comprehension.
The content of this sixth edition has been reorganized and
refreshed to integrate leadership and care management topics with
the nurse executive leadership competencies of the 2015 American
Organization of Nurse Executives (AONE) while revamping,
refocusing, and synthesizing the content. AONE has identified the
evidence-based core competencies in the field, and the content of
this book has been aligned accordingly to reflect the knowledge
underlying quality management of nursing services. This will help
the reader develop the crucial skills and knowledge needed for core
competencies.
The organizational framework of this book groups the 27
chapters into the following five parts:
Part I: Leadership aligns with the AONE competency category of
the same name and provides an orientation to the basic principles
of both leadership and management. Part I contains chapters on
Leadership and Management Principles, Change and Innovation,
and Organizational Climate and Culture.
Part II: Professionalism aligns with the AONE competency
category of the same name and addresses the nurse’s role and
career development. The reader is prompted to examine the role of
the nurse leader and manager. Part II discusses the content areas of
Managerial Decision Making, Managing Time and Stress, and Legal
and Ethical Issues.
Part III: Communication and Relationship Building aligns with
the AONE competency category of the same name. Part III focuses
on Communication Leadership, Team Building and Working With
Effective Groups, Delegation in Nursing, Power and Conflict, and
Workplace Diversity. These are essential knowledge and skill areas
for nurse leaders and managers as they work with and through
others in care delivery.
Part IV: Knowledge of the Health Care Environment covers the

21
AONE competency category of the same name and features a broad
array of chapters. Part IV encompasses Organizational Structure,
Decentralization and Shared Governance, Strategic Management,
Professional Practice Models, Case and Population Health
Management, Evidence-Based Practice: Strategies for Nursing
Leaders, Quality and Safety, and Measuring and Managing
Outcomes. This discussion highlights the importance of
understanding the health care organizational structures within
which nursing care delivery must operate. This section includes
information on traditional organizational theory, professional
practice models, and the dynamics of decentralized and shared
governance.
Part V: Business Skills aligns with the AONE competency
category on business skills and principles and contains an extensive
grouping of chapters related to Prevention of Workplace Violence;
Confronting the Nursing Shortage; Staffing and Scheduling;
Budgeting, Productivity, and Costing Out Nursing; Performance
Appraisal; Emergency Management and Preparedness; Data
Management and Clinical Informatics; and Marketing. These
chapters discuss the opportunities and challenges for the nurse
leader-manager when dealing with the health care workforce. The
wide range of human resource responsibilities of nurse managers is
reviewed, and resources for further study are provided. The
significant share of scarce organization budgets consumed by the
human resources of an institution makes this area of management a
key challenge that requires intricate skills in leadership and
management. This section examines some of the important factors
that nurse leader-managers must consider in the nursing and health
care environment. Also in this section are chapters that build on
organizational theory and demonstrate the importance of
integrating organizations and systems with the current technology
and theory applications, including data management and
informatics, strategic management, and marketing.
The 27 chapters in this text are organized in a consistent format
that highlights the following features:

• Concept definitions

• Theoretical and research background

22
• Leadership and management implications

• Current issues and trends

• Case Studies and Critical Thinking Exercises

• Research Notes

This format is designed to bridge the gap between theory and

practice and to increase the relevance of nursing leadership and
management by demonstrating the way in which theory translates
into behaviors appropriate to contemporary leadership and nursing
care management.

Text features
This book contains several interesting and effective aids to readers’
comprehension, critical thinking, and application.

Critical thinking exercises

Found at the end of each chapter, this feature challenges readers to
inquire and reflect, analyze critically the knowledge presented, and
apply it to the situation.

Research notes
These summaries of current research studies are highlighted in
every chapter and introduce the reader to the liveliness and
applicability of the available literature in nursing leadership and
management.

Case studies
Found at the end of each chapter, these vignettes introduce the
reader to the “real world” of nursing leadership and management
and demonstrate the ways in which the chapter concepts operate in
specific situations. These vignettes show the creativity and energy
that characterize expert nurse administrators as they tackle issues in

23
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 THE LOEB CLASSICAL LIBRARY. VOLUMES ALREADY
PUBLISHED. Latin Authors. APULEIUS. The Golden Ass.
(Metamorphoses.) Trans. by W. Adlington (1566). Revised by S.
Gaselee. 1 Vol. CAESAR: CIVIL WARS. Trans. by A. G. Peskett. 1 Vol.
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III, and IV. PROCOPIUS. Trans. by H. B, Dewing. Vols. I and II.
QUINTUS SMYRNAEUS. Trans. by A. S. Way. 1 Vol. SOPHOCLES. .
Trans. by-F. Storr. ; 2 Vols. ST. JOHN DAMASCENE: BARLAAM AND
IOASAPH. Trans. by the Rev. G. R. Woodward and Harold Mattingly. I
Vol. XENOPHON: CYROPAEDIA, Trans. by Walter Miller. 2 Vols.
 IN PREPARATION. Greek Authors. AESCHINES, C. D.
Adams, of Dartmouth College. AESCHYLUS, H. W. Smyth, of Harvard
University. ARISTOPHANES, J. W. White, of Harvard University.
ARISTOTLE, THE NICOMACHEAN ETHICS, Michael Heseltine, of New
College, Oxford. ARISTOTLE, THE POLITICS anp ATHENIAN
CONSTITUTION, Edward Capps, of Princeton University. ARRIAN, W.
K. Prentice, of Princeton University. ATHENAEUS, C. B. Gulick, of
Harvard University. CALLIMACHUS, A. W. Mair, Professor of Greek in
the University of Edinburgh ; ARATUS, G. R. Mair, of Gonville and
Caius College, Cambridge. CLEMENT OF ALEXANDRIA, Rev. G. W.
Butterworth, of the University of Leeds. DIO CHRYSOSTOM, W. E.
Waters, New York University. EUSEBIUS, Kirsopp Lake, of Harvard
University. GREEK LYRICS, J. M. Edmonds, of Jesus College,
Cambridge. HOMER, ILIAD, W. F. Harris, of Harvard University.
HOMER, ODYSSEY, A. T. Murray, of Stanford University. IAMBIC AND
ELEGIAC POETS, E. D. Perry, of Columbia University. ISAEUS, R. J.
Bonner, of the University of Chicago. ISOCRATES, G. Norlin, of the
University of Colorado. MANETHO, S. de Ricci. MENANDER, F. G.
Allinson, of Brown University. PAUSANIAS, W. H. S. Jones, of St.
Catherine’s College, Cambridge. PHILOSTRATUS, IMAGINES, Arthur
Fairbanks, Boston Museum of Fine Arts. PLATO, LYSIS AND
GORGIAS, W. R. Lamb, of Trinity College, Cambridge. PLATO,
REPUBLIC, Paul Shorey, University or Chicago. PLUTARCH, MORALIA,
F. C. Babbitt, of Trinity College, Hartford. POLYBIUS, W. R. Paton.
THUCYDIDES, C. F. Smith, of the University of Wisconsin.
XENOPHON, ANABASIS anp HELLENICA, C. W. Brownson, of the
College of the City of New York. 3
 Latin Authors. AMMIANUS, C. U. Clark, of Yale University.
AULUS GELLIUS, C. B. Platner, of Western Reserve University.
AUSONIUS, H. G. Evelyn White, of Wadham College, Oxford.
CICERO, AD FAMILIARES, E. O. Winstedt, of Magdalen College,
Oxford. CICERO, DE ORATORE, ORATOR,, BRUTUS, Charles
Stuttaford. FRONTINUS, DE AQUIS, C. Herschel, of New York.
FRONTO, C. R. Haines, of St. Catherine’s College, Cambridge. )
HORACE, EPISTLES anp SATIRES, W. G. Hale, of the University of
Chicago, and G. L. Hendrickson, of Yale University. JUVENAL anpD
PERSIUS, G. G. Ramsay, of Trinity College, Oxford, and late of
Glasgow University. LIVY, B. O. Foster, of Stanford University. LUCAN,
S. Reinach, Member of the Institute of France. OVID, TRISTIA anp
EX PONTO, A. L. Wheeler, of Bryn Mawr College. SALLUST, J. C.
Rolfe, of the University of Pennsylvania. SENECA, EPISTULAE
MORALES, R. M. Gummere, of Haverford College. SENECA, MORAL
ESSAYS, J. W. Basore, of Princeton University. TACITUS, ANNALS,
John Jackson, of Queen’s College, Oxford. VALERIUS FLACCUS, A. F.
Scholfield, of King’s College, Cambridge. VELEIUS PATERCULUS, F.-
W. Siepied of Washington University. VITRUVIUS, F. W. Kelsey, of the
University of Michigan. DESCRIPTIVE PROSPECTUS ON APPLICATVi
is ———————_ = SS SS = WILLIAM HEINEMANN. = G. P.
PUTNAM’S SONS. 4 London = New York =
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