Nursing Leadership and Management PDF

NCM 119: NURSING LEADERSHIP AND MANAGEMENT COURSE DESCRIPTION This course deals with the concepts, principles, theories and methods of developing nursing leaders and managers in the hospital and community-based settings. It also includes ethico-moral/legal aspects of health care an...

NCM 119: NURSING LEADERSHIP AND MANAGEMENT COURSE DESCRIPTION This course deals with the concepts, principles, theories and methods of developing nursing leaders and managers in the hospital and community-based settings. It also includes ethico-moral/legal aspects of health care and nursing practice and the nurses’ responsibilities for personal and professional growth.  NURSING LEADERSHIP AND MANAGEMENT A. Concepts of Leadership and Management B Leadership Theories C. Management Theories Leadership conjures up a variety of thoughts, reflections and images. These may include power, influence, followership, dynamic personality, charisma, goals, autocratic behaviour, innovation, cleverness, warmth and kindness (Curtis, de Vries & Sheerin, 2011)  LEADERSHIP DEFINES…. ‘The process by which an agent induces a subordinate to behave in a desired manner.’ (Bennis, 1959) ‘Leadership…is the ability to influence people toward attainment of goals.’ (Daft, 2000) ‘Leadership is defined as influence, that is, the art or process of influencing people so that they will strive willingly and enthusiastically toward the achievement of group goals.’ (Weihrich and Koontz, 2005) ‘Leadership involves the use of interpersonal skills to influence others to accomplish a specific goal.’ (Sullivan and Garland, 2010)  LEADERSHIP DEFINES…. A common theme that seems to run through many definitions is that ‘leadership involves influencing the attitudes, beliefs, behaviours and feelings of other people’(Spector, 2006). Although these definitions may be confusing, it is worth noting that there is no one correct definition of leadership. This vast range of definitions can contribute to a greater understanding of the many factors that influence leadership, as well as provide different perspectives of the concept (Hughes et al, 2006). MAHATMA GHANDI The leader in India’s Independence movement Form non-violent civil disobedience Gandhi is today remembered for his commitment to pacifism, peaceful protest and simple living. He single-handedly inspired millions of people to action, preaching a message of love, tolerance and avoiding greed WINSTON CHURCHILL Winston Churchill is long remembered as one of the greatest leaders in modern history and the savior of democracy. He was tasked with the daunting task of leading Britain and the Allied powers to victory against the Nazis during the Second World War. MARTIN LUTHER KING JR “I have a dream that my four children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character.” – Martin Luther King Jr Very few Americans are as celebrated as Martin Luther King Jr., the Baptist minister and social activist who led the Civil Rights Movement in the United States until his tragic death in 1968. NELSON MANDELA He is South Africa’s first democratically elected President Much like Martin Luther King, Jr., Mandela was one of the great transformative civil rights leaders of the 20TH century. MOTHER THERESA Mother Teresa’s unforgettable devotion to help the world’s poorest, most impoverished and vulnerable people left a lastin dent in the world. Her remarkable leadership was even powerful enough to cut across conflicts and enemy lines — a strength clearly exemplified during the 1982 Siege of Beirut. MANAGEMENT….. > is defined as the coordination and integration of resources through planning, organizing, coordinating, directing, and controlling to accomplish specific institutional goals and objectives. Hersey and colleagues (2013) defined management as the “process of working with and through individuals and groups and other resources (such as equipment, capital, and technology) to accomplish organizational goals”. They identified management as a special kind of leadership that concentrates on the achievement of organizational goal (Huber, 2011). LEADER VS MANAGER –Johnny Appleseed  LEADER MANAGER 1. Leaders create a vision, managers create goals 2. Leaders are change agents, managers maintain the status quo 3. Leaders are unique, managers copy. 4. Leaders take risks, managers control risk 5. Leaders are in it for managers think short-term. the long haul, 6. Leaders grow managers rely on existing, proven personally, skills. 7. Leaders build managers build systems and relationships, processes. 8. Leaders coach, managers direct. 9. Leaders create fans, managers have employees. 10. Leaders Think Ideas, Managers Think Execution Universal Principles of Management What is “Principles of Management”? Management principles are the statements of fundamental truth based in logic which provides guidelines for managerial making and actions.  The 8 universal principles of quality management 1.Customer focus 2.Leadership 3.People involvement 4.Process approach 5.Systematic approach to management 6.Continual improvement 7.Factual approach to decision making 8.Mutually beneficial supplier relations Principle 1: Customer focus The first, and arguably most important principle, argues that a business wouldn’t exist without its customers. Therefore, organisations should strive to understand their current and future customers, in order to better meet their requirements and expectations. Key benefits of cultivating good customer relationships include an increased market share and boost to revenue, as well as improved customer loyalty. If you are seen as understanding and reacting appropriately to consumer demand, the success of your business is pretty much guaranteed, so it’s worth paying close attention to this principle. Principle 2: Leadership This principle extols the virtues of strong, purposeful and unifying leadership. Leaders are responsible for creating a productive and progressive business environment. They also are in charge of ensuring that future hires maintain that atmosphere. Implementing this principle in your workplace relies upon having an established vision for the business, as well as the right leaders in place to promote that vision to the rest of the team. Spending some time getting this right from the get-go will save you time and stress in the future. Principle 3: People involvement Just as your business would be nowhere without a customer base, it also wouldn’t get very far without a balanced, multi-skilled team either. Employees at every level of the organisation are crucial to its success, and this principle is all about recognising that. As an employer it's vital to ensure that your team are motivated and engaged, not just in their day-to-day responsibilities, but also in the company as a whole. For this to happen, staff need to understand the importance of their role and how it fits into wider company objectives, as well as take responsibility for any problems that might impede them from doing their job to the best of their abilities. Principle 4: Process approach A process-driven approach can help companies to avoid logistical problems that often stem from confusion over the right way to go about things. It also future-proofs your business, as having set processes ensures that there’s no moment of flat panic when a key team member moves on, leaving everyone in the dark about key elements of their job. Developing processes for every area of your business, from sales to marketing, finance to HR, will ensure that resources are used most effectively, resulting in cost-effective and consistent results. It also allows you to dedicate time and attention to bigger and more exciting tasks! Principle 5: Systematic approach to management This principle is linked to the previous one, and argues that identifying, understanding and managing processes using a clear system will help to streamline your business. By ensuring that team members are dedicating the right amount of attention to key tasks, you’ll eliminate wasted time and make your business more efficient. A systematic approach also allows everyone to have access to every stage of certain processes and stay up to date with progress. Plus, it looks great for prospective new clients when your business is organised. Win-win. Principle 6: Continual improvement As the old adage goes, if you’re not going forwards, you’re going backwards. A business should always be pushing for improvements, because if you’re not, you can bet that your competitors will be. Continual progress is a permanent goal of any successful organisation. Take a look at the world’s top 10 most prosperous organisations and you can guarantee that they have entire teams dedicated to ensuring that they are always onto the next thing. Commitment to improvement also allows you to be the market leader, as you’ll be the ones setting the agenda, rather than playing catch-up to your competitors. Principle 7: Factual Approach to Decision Making This principle states that effective decisions are made based on rational analysis of data. Whilst a gut feeling can be useful in some situations, it won’t really stand up when you’re explaining to your board of investors why your profits are down by 10% this year. Before making any business decisions, big or small, ensure that you have all the facts. That way, if you’re ever questioned about why you made a certain decision, or asked to prove how that decision benefits your business, you’ll have all the data at your fingertips to fall back on. This principle also relies upon having access to reliable and accurate data, another vital aspect for a modern-day business. Principle 8: Mutually Beneficial Supplier Relations Okay, so you’ve got a fantastic management system, excellent customer relationships and a comprehensive business plan. There’s one thing missing – what are you delivering to your customers? Whether your business provides goods or services to customers, it’s likely you’ll rely on some sort of supplier. This principle dictates that relationships between your company and any suppliers must be mutually beneficial in order to add value to both parties. It allows both of you to react more quickly and flexibly to customer demands if things are smooth and harmonious between you, as well as making it easier to negotiate on costs.  Leadership Theories I. Early Leadership Theories A. Great Man Theory B. Trait theories Authoritarian Democratic Laissez-Faire II. Contemporary Leadership Theories A. Quantum Leadership B. Transactional Leadership C. Transformational Leadership D. Shared Leadership E. Servant Leadership F. Emotional Leadership A. Early Leadership Theories a.Great Man Theory – this theory assumed that all leaders were men and all were great. Those who assumed leadership roles were determined by their genetic and social inheritance. It was not conceivable that those from the “working class” could be leaders, that leadership could be learned or that women could be leaders. A. Early Leadership Theories b.Trait theories – theorist have sought to understand leadership by examining the characteristics of leaders. Leaders arise in a context, and they are said to be made, not born. They appear to learn leadership skills in stages. Thus, leadership skills can be both taught and learned. It is important for nurses to recognize that they can learn, practice, and improve their personal leadership competencies. Leadership theory began to move beyond a focus on traits to explore the concept of leadership styles. They are defined as different combinations of task and relationship behaviors used to influence others to accomplish goals. Three distinct leadership styles: 1. Authoritarian 2. Democratic 3. Laissez-Faire Authoritarian Uses primarily directive behaviors. Decisions of policy are made solely by the leader who tends to dictate tasks and techniques to followers. Leaders tell the followers what to do and how to do it. This style can create hostility and dependency among followers; it may also stifle creativity and innovation. On the other hand, this style can be very efficient, especially in a crisis. Democratic This approach implies a relationship and person orientation. Policies are a matter of group discussion and decision. The leader encourages and assists discussions and group decision-making. Human relations and teamwork are the focus. The leader shares responsibility with the followers by involving them in decision making. Democratic In nursing, interdisciplinary teamwork is a major element in effectiveness. The democratic style makes output appear to move more slowly and is thought to take longer than using an authoritarian style. Group consensus needs time and facilitation to be fostered. Intergroup cohesion is a focus with this style. Laissez-Faire This style promotes complete freedom from group or individual decisions. There is a minimum of leader participation. A leader using this style may seem to be apathetic. Because the style is based on noninterference, a clear decision may never be formulated. It results in a decision, conscious or otherwise, to avoid interference and let events take their own course.  Laissez-Faire The leader is either permissive and fosters freedom or in inept at guiding a group. Followers may need greater structure than the leader gives them. Despite its potential drawbacks, this style has advantages when used with groups of fully independent care providers or professionals working together. Behavioral theories In this view, personal traits provide only a foundation for leadership; real leaders are made through education, training and life experiences. Contingency Theories This suggest that managers adapt their leadership styles in relation to changing situations. Leadership behaviors range from authoritarian to permissive and vary in relation to current needs and future probabilities. A nurse manager may use an authoritarian style when responding to an emergency situation such as a cardiac arrest but use a participative style to encourage development of a team strategy to care for patients with multiple system failure. II. Contemporary Leadership Theories A. Quantum Leadership B. Transactional Leadership C. Transformational Leadership D. Shared Leadership E. Servant Leadership F. Emotional Leadership  a. Quantum Leadership is based on the concepts of chaos theory. Is the process of leading from the future Reality is constantly shifting, and levels of complexity are constantly changing. Movement in one part of the system reverberates throughout the system. Roles are fluid and outcome oriented. It matters little what you did; it only matters what outcome you produced. Within this framework, employees become directly involved in decision making as equitable and accountable partners, and managers assume more of an influential facilitative role, rather than one of control (Porter-O’Grady & Malloch, 2010).  a. Quantum Leadership Fundamental requirements of quantum leadership: Acting with moral purpose to make a positive difference in the lives of organizational members and soceity as a whole. Building relationships that nurture both individuals and organization. Patients and staff alike can access untold amounts of information. The challenge, however, is to assist patients, uneducated about health care, how to evaluate and use the information they have. Because staff have access to information only the leader had in the past, leadership becomes a shared activity, requiring the leader to possess excellent interpersonal skills. b. Transactional Leadership Is based on the principles of social exchange theory. The primary premise of social exchange theory is that individuals engage in social interactions expecting to give and receive social, political, and psychological benefits or rewards. The exchange process between leaders and followers is viewed as essentially economic. Once initiated, a sequence of exchange behavior continues until one or both parties finds that the exchange of performance and rewards is no longer valuable. b. Transactional Leadership The nature of these transactions is determined by the participating parties’ assessments of what is in their best interests; for example, staff respond affirmatively to a nurse manager’s re- quest to work overtime in exchange for granting special requests for time off. Leaders are successful to the extent that they understand and meet the needs of followers and use incentives to enhance employee loyalty and performance. Transactional leadership is aimed at maintaining equilibrium, or the status quo, by performing work according to policy and procedures, maximizing self-interests and personal rewards, emphasizing interpersonal dependence, and routinizing performance (Weston, 2008). Transformational Leadership It goes beyond transactional leadership to inspire and motivate followers (Marshall, 2010). Transformational leadership emphasizes the importance of interpersonal relationships. Transformational leadership is not concerned with the status quo, but with effecting revolutionary change in organizations and human service. Whereas traditional views of leadership emphasize the differences between employees and managers, transformational leadership focuses on merging the motives, desires, values, and goals of leaders and followers into a common cause. The goal of the transformational leader is to generate employees’ commitment to the vision or ideal rather than to themselves. Transformational Leadership Transformational leaders appeal to individuals’ better selves rather than these individuals’ self-interests. They foster followers’ inborn desires to pursue higher values, humanitarian ideals, moral missions, and causes. Transformational leaders also encourage others to exercise leader- ship. The transformational leader inspires followers and uses power to instill a belief that followers also have the ability to do exceptional things. Transformational Leadership Transformational leadership may be a natural model for nursing managers, because nursing has traditionally been driven by its social mandate and its ethic of human service. In fact, Weberg (2010) found that transformational leadership reduced burnout among employees, and Grant et al., (2010) reports transformational leadership positively affected the practice environment in one medical center. Transformational leadership can be used effectively by nurses with clients or coworkers at the bedside, in the home, in the community health center, and in the health care organization. d. Shared Leadership Reorganization, decentralization, and the increasing complexity of problem solving in health care have forced administrators to recognize the value of shared leadership, which is based on the empowerment principles of participative and transformational leadership (Everett & Sitterding, 2011). Essential elements of shared leadership are relationships, dialogues, partnerships, and understanding boundaries. The application of shared leadership assumes that a well-educated, highly professional, dedicated workforce is comprised of many leaders. It also assumes that the notion of a single nurse as the wise and heroic leader is unrealistic and that many individuals at various levels in the organization must be responsible for the organization’s fate and performance.  d. Shared Leadership Different issues call for different leaders, or experts, to guide the problem-solving process. A single leader is not expected always to have knowledge and ability beyond that of other members of the work group. Appropriate leadership emerges in relation to the current challenges of the work unit or the organization. Individuals in formal leadership positions and their colleagues are expected to participate in a pattern of reciprocal influence processes. e. Servant Leadership Founded by Robert Greenleaf (Greenleaf, 1991), servant leadership is based on the premise that leadership originates from a desire to serve and that in the course of serving, one may be called to lead (Keith, 2008; The Greenleaf Center for Servant Leadership, 2011). Servant leaders embody three characteristics: Empathy Awareness Persuasion (Neill & Saunders, 2008) e. Servant Leadership Servant leadership appeals to nurses for two reasons: First, our profession is founded on principles of caring, service, and the growth and health of others (Anderson et al., 2010). Second, nurses serve many constituencies, often quite selflessly, and consequently bring about change in individuals, systems, and organizations. f. Emotional Leadership Emotional intelligence involves personal competence, which includes self-awareness and self-management, and social competence, which includes social awareness and relationship management that begins with authenticity.  f. Emotional Leadership Goleman (2007) asserts that attachment to others is an innate trait of human beings. Thus, emotions are “catching.” Consider a person having a pleasant day. Then an otherwise innocuous event turns into a negative experience that spills over into future interactions. Or the reverse. A positive experience lightens the mood and affects the next encounter. When people feel good, they work more effectively. f. Emotional Leadership Emotional intelligence has been linked with leadership (Antonakis, Ashkanasy, & Dasbor- ough, 2009; Cote et al., 2010; Lucas, Spence-Laschinger, & Wong, 2008). One study, however, found no relationship between emotional intelligence and transformational leadership (Linde- baum & Cartwright, 2010). f. Emotional Leadership Nurses, with their well-honed skills as compassionate caregivers, are aptly suited to this direction in leadership that emphasizes emotions and relationships with others as a primary attribute for success. These skills to better with the more contemporary relationship-oriented theories as well. Thus, the workplace is a more complex and intricate environment than previously s u g g e s t e d. MANAGEMENT THEORIES 1. Early Management Theories II. Contemporary Management Theories EARLY MANAGEMENT THEORIES A. Traditional i. The Scientific Management Movement ii.General Administrative Theory iii. Bureaucratic Management B. The Behavioral Management Movement C. Theory Z: Japanese Management Style CONTEMPORARY MANAGEMENT THEORIES 1. Contingency Theory 2. Systems Theory 3. Complexity Theory 4. Chaos Theory i. The Scientific Management Movement Frederick Winslow Taylor (1856-1915) is known as the father of scientific management. He detailed his principles on increasing the productivity of workers in the Midvale Steel Works plant in Pennyslvania. The industrial Revolution gave rise to large factories and created the need to organize the efforts of the superviors and workers in the factories. Taylor’s scientific management principles were based on managing time, materials and work specialization. He developed the concept of time and motion study, with the idea that wasted time and effort could and should be eliminated. This was used in hospital facilities in 1980’s to determine patient:nurse ratios and staffing needs.  ii. General Administrative Theory Henri Fayol (1841-1925) was a Frenchman who is remembered for the development of general administrative theory. He developed his management strategy in the mining industry. Management, according to Fayol’s work, includes 5 overriding concepts: 1.prevoyance, or the anticipation of the future and the development of a plan of action to deal with it; 2.organization of people and materials; 3.command of the activity among personnel; 4.coordination of the parts of the organization into a unified whole; 5.control through application of rules and procedures. In order for an organization to be productive leaders must participate actively in all five of these areas.  ii. General Administrative Theory These principles introduced some ideas that continue to be used. In the 21st century, hospital personnel departments continue to have a pay scale that strives to provide far remuneration based on educational preparation and years of experience. Every organization strives to retain its staff because of the cost of recruiting, training, and orienting new employees. The development of “esprit de corps”, or team spirit, continues to be important in todays workplace. Teamwork remains essential to providing optimal patient care, and high morale is conducive to the levels of collaboration and team work that are required in the complex health care environment. ii. General Administrative Theory Patient care is delivered by a collaborative team of knowledge workers including nurses, physicians, and therapists from a variety of disciplines, all of whom are necessary to the outcome of optimal patient care. iii. Bureaucratic Management Max Weber (1846-1920) was a German sociologist who developed what was known as the “ideal bureaucracy”. The ideal bureaucracy includes the concepts of division of labor, authority hierarchy, formal selection, formal rules and regulations, impersonality, and career orientation. iii. Bureaucratic Management Within health-care organizations today, one sees the continuing influence of traditional management theory in, for example, job descriptions that outline the responsibilities of each person, thereby dividing the labor, and in organization charts that depict the hierarchical structure and the areas of authority for particular positions. Job descriptions emphasize the functions to be associated with each job, and one of the functions of the manager is to avoid overlap between positions and to delineate clearly the functions expected. These methods are helpful in that job descriptions let workers know the expectations and responsibilities associated with the positions they occupy. iii. Bureaucratic Management However, it is also true that work would not get done if the only functions carried out each day were limited to those outlined on the job description. The work to be accomplished is too complex to be listed in a document of any reasonable length. In addition, the complexity of the health-care environment is such that people need to be treated as knowledge workers and allowed to have both the responsibility and the authority to make decisions about operational issues.  The Behavioral Management Movement The recognized beginning of the behavioral movement was a much cited study that lent its name to the Hawthorne Effect. Elton Mayo (1887–1957), a clinical psychologist working at the Harvard Business School, conducted studies at the Hawthorne plant of the Western Electric Company from 1927 to 1932. Mayo designed a study in which light levels in the workplace were first increased, during which time worker productivity increased. Subsequently, he lowered the light levels, and yet worker productivity continued to improve. His conclusion was that the environmental changes were not responsible for the increasing level of productivity but rather the fact that the workers received attention from the experimenters, which increased levels of self-esteem and group pride, which led to increased production. The Behavioral Management Movement It was from this study that Mayo concluded that management must be concerned with preserving the dignity of the workers, demonstrating appreciation for their accomplishments and, in general, recognizing workers as social beings with social needs (Mayo, 1953). This has great implications for research because it is always possible that results may be altered by the very acts of observation and increased attention. This threat to validity has become known as the Hawthorne Effect, after the name of the company where Mayo conducted his research. The Behavioral Management Movement Another well-known behavioral theorist, Douglas McGregor (1960), developed Theory X and Theory Y.  Theory X and Theory Y Theory X represented the traditional viewpoints of management, which hold managers responsible for organizing money, materials, equipment, and people as well as for directing workers’ efforts and motivating workers, controlling their actions, and modifying their behavior to fit the needs of the organization. Theory X suggests that, without active intervention by management, workers would be passive and nonproductive in their roles in the organization. Theory Y assumes that the desire to work is just as natural as the desire to play or rest, that external control and threat or punishment are not required to achieve organizational objectives because workers are self-motivated, and that the capacity to work creatively to solve problems is widely distributed in the workforce.  Theory X and Theory Y McGregor believed that these were the two major managerial attitudes about employees and that these approaches directly affect how the employee responds to managerial leadership (Marquis & Huston, 2006).  Theory Z: Japanese Management Style In 1981 William G. Ouchi wrote a book on Japanese management style, entitled Theory Z. In this book he discussed the management methodologies used by Japanese corporations. This approach to management relied on principles that were diametrically opposed to those used in businesses in the West, including America, England, and Europe. Employment in the Japanese corporation is described as being lifelong, dependent upon the development of consensus, collaborative work, incentives for group work, and pride in the product or service being developed or provided. Theory Z: Japanese Management Style In Japan, the word kaizen refers to the principle of encouraging all people in the organization to contribute improvement ideas on a biweekly basis (Bodeck, 2002). This results in 24 improvement ideas per employee each year, compared with one idea per employee per year in the United States and one idea per 6 years, on average, in the United Kingdom. Organizational growth has been shown to be directly related to innovation. The more leadership encourages participation and ownership among the employees, the more productive the organization becomes. Theory Z: Japanese Management Style Ouchi (1981) discusses the importance of encouraging group contributions. In Japan, individuals rarely desire personal recognition because they believe that nothing is possible without everyone’s contributions. Although in the United States the predominant values focus on individual accomplishments, it is increasingly recognized that shared governance, which recognizes the importance of contributions from every employee, is the desired model. Contemporary Management Theories A variety of contemporary theories of management have arisen to help organize management thought. Four major management theories now predominate: Each one contributes principles useful for nursing management and administration and for nurse managers working to coordinate and integrate health care delivery 1. Contingency Theory Considered to be a leadership theory but it also applies to management. The basic principle is that managers need to consider the situation and all its elements when making a decision. Managers need to act on the key situational aspects with which they are confronted. Sometimes described as “it all depends” decision making, contingency theory is often used for choosing a leadership or management style. The “best” style depends on the situation. 2. Systems Theory It has helped managers to recognize their work as being embedded within a system and to better understand what a system is. Managers have learned that changing one part of a system inevitably affects the whole system. General systems theory is a way of thinking about studying organizational wholes. 2. Systems Theory It uses the following concepts: Organization Wholeness Control Self-regulation Purposiveness Environment Boundaries Equilibrium Steady State Feedback 2. Systems Theory A key principle of systems theory is that changes in one part of the system affect other parts, creating a ripple effect within the whole. Using systems theory implies a rational approach to common goals, a global view of the whole, and an emphasis on order rather than chaos. 2. Systems Theory In health care, concepts such as interrelatedness and interdependence fit well with multidisciplinary teamwork and shared governance professional models. However, concepts attaining a steady state and equilibrium are difficult to reconcile with the reality of uncertainty, risk, change and ambiguity that characterize the turbulence of the change occurring in the health care delivery environment. Previously, managers were advised to draw up 5-year and even 10-year plans, managers today have seriously shortened their strategic planning and other related time lines in response to the rapidity of change. 2. Systems Theory An example of the use of systems theory is basing an analysis of a planned change, such as implementing a new program, on systems concepts by identifying inputs, throughout, outputs, and feedback loops to more effectively plan how the new program fits into the existing system. Sometimes this process is used for short time frame rapid response team projects.  3. Complexity Theory It is a more general umbrella theory that encompasses chaos theory. The focus of this theory is the behavior over time of certain complex and dynamically changing systems. The concerns is about the predictability of the behavior of systems that under certain conditions perform in regular and predictable ways but in other conditions change in irregular and unpredictable ways, are unstable, and move further away from starting conditions unless stopped by an overriding constraints. 3. Complexity Theory Key findings of complexity theory are the “effective unknowability” of the future and an understanding of the role of creative disorder. Managers need to alter their reflexive behaviors, put an emphasis on “double-loop learning” that also examines the appropriateness of operating assumptions, foster diversity, be open to strategy based on serendipity, welcome disorder as a partner, use instability positively, provoke a controlled ferment of ideas, release creativity, and seek the edge of chaos in the complex interactions that occur among people.  4. Chaos Theory Most would agree that one characteristic of nursing is its unpredictability, its chaos and complexity. To use a theory about chaos and complexity is intuitively attractive. Sometimes no matter how hard nursing leaders try to maintain consistency and control, things do become chaotic. Chaos is commonly known as disorganization and disorderliness, but the meaning for this concept in chaos theory is quite different.  4. Chaos Theory It refers to behavior that is unpredictable in spite of certain regularities. There are many implications of chaos theory for health care delivery systems. The slightest variation can have enormous results in a dynamic and changing system. What is important is the quality of a system, its complexity, its distinguishing shapes, how it develops and changes, and how it differs from or compares with another system. In many ways, this highlights what nurses have known: the whole of nursing is complex and crucial to health care delivery systems in which nurses are major care coordinators.