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Nursing Management and Change Theory
In preparation for the upcoming inspection, several factors need to be considered and weighed by the nursing manager before actions are implemented. It is understood that when any large national health care corporation takes over a smaller hospital or system of hospitals, it is viewed primarily as a financial venture. The corporation as a whole views the medical aspects secondarily.
Following is a list of the types of considerations to be evaluated.
Is your unit making or costing the hospital money?
Is your unit using cost-effective measures in treating the patients?
Is your unit concerned only with health care and not bottom line costing?
Is your unit demonstrating a careful balance between excess cost and above-average health care for your patients?
Are there waste margins that can be trimmed? (e.g., using 4x4s with 3x3s would suffice? charting all consumables used so that proper billing can be done without incorrect billing (over or undercharging)? tracking patient use items carefully so auditing of billings from your unit do not require excessive time and return credits to insurance companies?
Is your staff being used most effectively? For example, some nursing staff function optimally during certain hours of the day - e.g., more alert at 6 a.m. than 6 p.m., and others work best with specific types of patients (i.e., females vs. males, quadriplegics vs. ambulatory) Note: in this environment, some of these variables cannot be completely addressed: all shifts must be staffed, all patients must receive the best possible care, and so on, but wherever possible are you placing "round pegs into round holes"?
Actions Required for Preparation
In preparing for the inspection and staff audit, the nursing manager must recognize himself or herself as the 'change agent' with all of the attendant costs and responsibilities. There will be a high level of resistance to the changes from staff, a strong undercurrent of fear for their jobs, and they will look to the nursing manager as the center of "control, resilience, and hardiness."
As nursing manager, effecting change as a "Hero Model" (i.e., proposing organic change models with commitment rather than compliance) will not be considered for this project but rather a process of teaching and conveying the changes as a process and not a singular event with the eminent need for "unfreezing, changing, and refreezing" in order to effect positive and long-term changes.
Theoretically, all forms of learning and change start with some form of dissatisfaction or frustration generated by data that disconfirm our expectations or hopes. Disequilibrium based on disconfirming information is a pre-requisite is requisite for change.
Disconfirming information is not enough, however, because we can ignore the information, dismiss it as irrelevant, blame the undesired outcome on others or fate, or, as is most common, simply deny its validity.
In order to become motivated to change, we must accept the information and connect it to something we care about. The disconfirmation must arouse what we can call "survival anxiety" or the feeling that if we do not change we will fail to meet our needs or fail to achieve some goals or ideals that we have set for ourselves ("survival guilt").
Critical thinking will be necessary when establishing areas rife for change. Knowing that the underlying reason for change with the large national health care corporation is economics and the nursing manager's reasons for change include economics, patient care, staff retention, and personal position control and continuation, critical thinking will involve some of the following elements:
are all of the current staff necessary to the end goal of efficient and competent patient care?
A is the department overstaffed? (note that this is rarely a field in which much margin for change is present; most hospitals are understaffed and those who could be considered overstaffed - by economists - need each staff member to maintain high quality service and care can the level of education, knowledge, and experience of all staff members (including nursing manager) justify the department's costs and existence?
Problem: department heads are the ones being considered for retention or release, therefore, if this nursing manager's department is not efficient, cost-effective, and team oriented, the position could be eliminated or nursing manager could be replaced.
Resolution: who - nursing manager, what - management results and methodology, where - with department personnel, when - consistently, why - ultimately to ensure quality patient care, secondarily to please new shareholders and maintain personal career position.
Conclusion: in order to maintain current appointment as nursing manager, current methods of doing things will need to be scrutinized by unfreezing the "way it has always been done," changing those elements which need to be modified, and refreezing the paradigm with attitudes and improvements intact.
Incorporating Theory with Strong Leadership
The staff reporting to the nursing manager must see the changes begin here; consistent adherence to logical changes (e.g., unit clerks onsite for codes to manage paperwork, supplies, chain of delivery, and time/event recording, thereby freeing medical professionals to do the most efficient work possible for the patient's well-being and efficacy of movement and objective accomplishment), and a firm demand for compliance to effected changes.
Theoretically, every patient should be the first to receive attention and care; this is impractical based on factors such as triage priority (cardiac events, hemorrhage, GSWs, MVAs, and so on), staffing levels (would require a minimal 3:1 ratio), and other limitations.
Conclusion: the effective nursing manager will lead from example (e.g., do as I do, not as I say), not from summary dictates (e.g., do as I say, not as I do).
In restructured health services, nurse managers should be directly responsible for managing nursing services. They advise other managers whose staff includes nurses on matters pertaining to professional nursing.
Leadership is an essential component of management. It is also critical that the nurse leaders are personally prepared and developed for hands-on care nursing.
Nursing leadership includes coaching and mentoring others, and creating an environment and conditions for ongoing development and quality care. Leadership through professional nurses associations develops the profession and positions it strategically to influence health planning and policy.
Maintaining networks and linkages with and between key stakeholders is essential to effective leadership and management. Also critical is the ability to continually assess the environment, to monitor performance, and to create or adapt to change as required.
Educational preparation for management will vary according to the roles and career paths of nurse managers. Professional nursing associations can assist by identifying relevant opportunities and promoting these to their members. Individual nurses must take responsibility for their own education, and develop the ability to plan and manage this strategically.
The preparation of nurses for management and policy should enable them to assume roles as either managers of nursing services or education, or as managers of health care services, or in health policy. In developing nurses as managers, it is recognized that leadership development is a critical component of management development, as well as being a major priority for nursing generally.
Nurses need to select appropriate uni- or multi-disciplinary programs to prepare them effectively for management, policy development and leadership in different settings and at different stages of their professional and career development. Preparation should support the importance of continuous learning that is adapted to changing needs and expectations. It should include emphasis on the development of relevant skills and attributes, not just the acquisition of knowledge.
Achievements of nurse managers need to be rewarded in the same ways as other managers. At the same time nurse managers need to demonstrate the benefits of their inclusion in key positions. Appropriate position classifications, equal to other managers at the same level and according to their professional attributes and their level of responsibility, should apply to nurse managers.
This nurse manager will look for areas of improvement - following a close, objective review of systems currently in place - and implement reasonable change within the 2-week timeframe allotted. It will be important to note, however, that there will be non-negotiables in the change process (e.g., salary boundaries, compromise in patient care, and so on) and a time-constraint in how much can be implemented.
Effective change management (and it is clear that a measure of change must take place in this situation to meet the requirements of the inspection) lies in the various kinds of tactics that change agents employ to create psychological safety.
For example, working in groups, creating parallel systems that allow some relief from day-to-day work pressures, providing practice fields in which errors are embraced rather than feared, providing positive visions to encourage the learner, breaking the learning process into manageable steps, providing online coaching and help all serve the function of reducing learning anxiety and thus creating genuine motivation to learn and change.
Unfortunately, however, motivation is not enough. A theory or model of change must also explain the actual learning and change mechanisms, and here Lewin's cognitive models were also very helpful in providing a theoretical base.…[continue]
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