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The "Case in Health Care Management" is a regular feature of The Health Care Manager. Readers are invited to analyze the problem presented in the case and develop a reasonable response to the situation.


In analyzing a case:


* look for the principles that appear to be involved, and look for the applicability of rules of reason, common sense, and fairness.


* Seek help from published sources. Associate the concerns of the case with key words that describe principles, concepts, theories, or techniques, and look these up in texts on supervision and basic management.


* Make whatever reasonable assumptions you need to "fill in the blanks" in the information given.


* Keep your assumptions reasonable, and state your key assumptions in your conclusions.


* Recognize that there are few solutions to a case problem that are entirely right or wrong. You are dealing primarily with human behavior, and all people will not necessarily behave the same way in similar situations.



After working 8 years as a staff nurse on a medical/surgical unit, Julie was appointed nurse manager for that unit. Following a staff meeting at which her promotion was announced, Julie found herself the center of a group of 3 of her coworkers offering their congratulations and making other comments.


"I'm really happy for you," said Sarah, "but I suppose this means our car pool is disrupted. Your hours are bound to be less predictable now."


Elaine said, "And the lunch bunch, too. Management commitments, you know." The emphasis on "management" was undeniable, and Julie was not at all sure she was happy with what she was hearing.


Jane offered, "Well, maybe now we can get some action on some age-old problems. Remember, Julie, you used to gripe as much as we did."


"We've all griped a lot," Sarah agreed. "That's been sort of a way of life around here." Her tone changed and her customary smile faded as she added, "Now Julie's going to be in a position where she can do something, so let's hope she doesn't forget who her friends are."


Elaine and Jane looked quickly from Sarah to Julie. For an awkward 10 seconds or so nobody spoke. At last someone passing by spoke to Julie, and as Julie turned to respond, the other 3 went their separate ways.




1. What possible advantages might Julie have in becoming manager of the group of which she has long been a member?


2. What are the possible disadvantages that may present themselves to Julie?


3. If you were Julie, how do you believe your promotion would affect your relationships with your former coworkers?




Readers are invited to submit their written analysis of this issue's case for possible publication in HCM 25:4 (October-December 2006). This is not a contest. Because a solution to a case may be neither completely right nor completely wrong, there will be no winners or losers. We will select one solution that appears particularly appropriate or relevant, or we may elect to publish excerpts from several proposed solutions.


Responses to this issue's "No Longer 'One of the Gang'" should be submitted under the following conditions:


1. The analysis should be typed and double-spaced. It should not exceed 300 words.


2. The response should be postmarked no later than July 15, 2006, and should be mailed to: Charles R. McConnell, Editor, HCM, 5943 Walworth Road, Ontario, New York 14519, or e-mailed by that date to the Editor at


3. The response should include the responder's full name, title, organization, and complete mailing address.


4. The editor will notify anyone whose response is selected for publication. Selected responses will be subject to normal editing for language and style.


5. Unused responses cannot be acknowledged or returned.



When you accepted your new job as manager of plant engineering your immediate superior, vice president for environmental services Patrick Jones, told you that you would not find a great deal of decision-making guidance in written form. As Jones expressed it, "Common sense is the governing policy." But Jones also cautioned you about the necessity to see him about matters involving employee discipline because the organization was especially sensitive to union overtures in the service areas at the present time.


Early during your third week on the job, a matter arose which seemed to you to call for routine disciplinary action. Remembering Jones's precaution, you tried several times to see him over a period of 3 days. Being unable to reach Jones and receiving no response to your specific messages, you went ahead and took action on your own rather than risk losing credibility through procrastination. When you were finally able to get a meeting with Jones some several days later you described the situation and the action you had taken. Jones agreed with you, and of your concern for getting to him quickly he said, "What's the big deal? As I said, common sense is the best policy and yours was a common-sense decision."


When a similar situation arose some weeks later and you could not get to Jones, although you tried to reach him several times, once again you took action. However, this time the disciplinary action involved an employee you later learned was a vocal informal leader of a sizable group of discontented employees. The action backfired on you and provided the union organizers with an issue that they instantly took up as a rallying point.


Jones was furious with you, accusing you of deliberately overreaching your authority by refusing to bring such problems to his attention as he had directed.




Develop a tentative approach to the determination of the boundaries of your decision-making authority. Because the limits of your authority are ultimately those limits set by your boss, you need to develop a possible approach for getting Jones to help you define the limits of your authority.



No reader responses were received for the case titled "Looking for Boundaries" appearing in HCM 24:4 (October-December 2005). Following are some thoughts that might appear in a reasonable response.


You find yourself in the unenviable position of lacking a clear understanding of the limits of your authority. When these "flexible" boundaries on your decision-making authority are communicated via your manager s mixed signals, you might find yourself virtually paralyzed in attempting to decide anything (if your nature runs to the overly cautious). Alternatively, you might find yourself frequently, if not constantly, in trouble (if your nature leads you to take charge and run with most situations).


Jones's rather flip attitude is "do what I would do under the circumstances," but until you get to know him well, you will experience many doubts in deciding what he would be likely to do. His assertion that "common sense is the best policy" is inappropriate because the direction that common sense may suggest will differ according to the circumstances of the immediate situation.


You have, however, learned something important about your manager fairly early in your relationship: you have learned about his capacity for inconsistency and unpredictability, and this knowledge is going to influence you in the way in which you relate to him.


Until you become really familiar with Jones s quirks and foibles, whenever he puts you in a seemingly independent decision-making position, it would be helpful to try to envision both the best and worst possible outcomes of any decision situation. In this manner you can let potential consequences be one of your decision-making guides.


In addition, you may simply have to ask the guidance of Jones more often than he thinks is necessary, at least until you know him and his ways better. Over time you can develop a picture of how soft or flexible the boundaries of your position might be and adjust much of your behavior accordingly.