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Supervising nursing personnel, like supervising in any other profession, demands more these days than simply telling the nurse what needs to be done, expecting it to be done, and saying "Good Job," it the spirit moves you. Especially in nursing, supervisory skills are increasingly important as the profession comes under more and more pressure from several fronts at once: health care organizations looking for ways to save money; fewer students choosing to go into nursing because they've heard the tales of killer hours and their negative lifestyle impact, and; pressures to keep up with expanding technology, often without commensurate upgrading of pay, title or other perks.
This paper will outline the pressures on nursing that mandate improved supervisory tactics and the characteristics of today's nurse population. Finally, it will offer some insight into how best to supervise today's nurses, and some tactics to make it all work.
Pressures on the nursing profession:
Hospitals compete for managed care contracts, and managed care companies use their clout to demand the most for the money. So hospitals, looking at lower fees from both HMOs and Medicare (even before current moves afoot in Congress to further curtail Medicare and Medicaid payments), are looking for ways to shave expenses. Registered Nurses "represent 23% of the hospital workforce and are the biggest share of labor costs (and are only 10% unionized)," making downsizing RN staff all but irresistible. (Gordon, 2000)
Downsizing has happened through layoffs and by attrition, and the gap has been filled partially by unlicenses assistive personnel (UAPs), who earn 20 to 40% less than RNs. This in itself leads to a supervision dilemma for those in charge of RNs: although no state regulates the education of UAPs, under state licensure rules, the Rncan be held reponsible for any mistakes made by UAPs working under the nurse's supservision -- and all UAPs are considered to be working under RN supervision -- and can lose his or her license as a result of those mistakes. Worse still, the UAPs, after only a few hours' training on the job, may change dressings, insert urinary catheters or clean tracheostomy tubes, among other demanding tasks. So the nursing supervisor is faced with not only keeping the RNs productive, but with sellign them on the idea that they could lose their licenses over an issue and practice over which they have no control. (Gordon, 2000)
It has been found, too, that nurses often do not trust the UAPs, and refuse to delegate to them, thereby further burdening themselves. Even when a facility's UAPs have been adequately prepared for a correctly written job description, the nursing staff may not be as familiar with all that as they might be, which is again a nursing supervisory task that needs to be done. Along with that is lack of preparation of the nurses, though orientatin and education, concerning increasing and proper utilization of UAPs. (Nyberg, 1999) And, in addition to adding to the nursing supervisor's role, it adds a significant supervisory role to the RN's workload because, in order to use UAPs effectively and safely, the RN must:
Assess the patient's condition,
Consider the complexity of the patient's condition,
Consider the complexity of technology and the procedure,
Be aware of and understand the predictability of patient outcomes,
Know the level of preparation and education of the UAP,
Know the competency of the UAP. (Nyberg, 1999)
More changes in task
Supervising UAPs is a change in the traditional nurse's job description. Nursing staffs, once made up of 85-95% RNs with only 5-15% aides, are now only 70 or 80% RNs, with the rest aides. In some cases, the split is 50-50. And even though the American Hospital Association (AHA) reports that the number of nurses employed actually rose from 858,909 in 1992, to 901,198 in 1997 (although they don't give figures beyond that), the AHA does not mention that now, many of those nurses are involved in administrative tasks, creating reports for insurance, oversight and government bodies, and not doing hands-on nursing at all, (Gordon, 2000) which makes the supervisory problem much more difficult on two counts: even fewer nurses doing even more work than first imagined, and nurses doing work they hardly went through nursing school to pursue in most cases.
Increased patient load, mandatory overtime
Nor does the AHA mention that between 1994 and 1997, there was an 8.8% increase in the average number of patients for which each RN cared. Add to that the trend toward discharging patients as soon as they are even marginally able to leave, and it means that all those extra people being cared for are not at various stages in an illness or post-operative recovery; virtually all of them are at the upper extreme edge of needing nursing care. How those numbers actually work in practice paints an even more frightful picture. For example, if a nurse who arrives at 7 a.m. has seven patients to care for, four may be discharged at noon. By 1 p.m., she has four new patients in those beds, with four different problems, histories, etc., making a real total of 11 patients on her roster that day, not to mention all the added stress of discharging and admitting four patients while continuing care for three. And then, just when the nurse is due to leave for much-needed recharging and rest, he is told that the next shift is short one nurse and none are available from the agencies, so he must work mandatory overtime. (Gordon, 2000) All this, too, makes the supervisory role that much more difficult and that much more necessary.
Pay rate, hours disparity
If pay rates more than made up for the stress, maybe that would give some ease to the problem of supervising nursing personnel. But in fact, there is some unfortunate disparity there, considering the increase in hours expectations noted above. There has been some increase in average hourly earning for nurses in the past 15 years, but compare it to the increases in hours worked to determine its value, considering the already-stressful environment and the problems noted above. Between 1987-1992, there was a 5.6% wage increase; between 1992 and 1997, the increase was 3.5%. In 1998, the increase was 4.5%. But the increase in hours, between 1988 and 1998 was about 32%. (Engel, 1999)
In March 1984, an 18-year-old girl died at New York Hospital after tearing an IV from her arm, and climbing out of bed, her face a red glow of fever. The nurses called for help, but neither the attending doctor nor a resident responded. The result, fortunately, was that state's board of inquiry decided that residents should no longer be made to work 80-hour shifts because it ended up in them being so tired, they literally did not waken from naps for essential requests like those of the New York Hospital nurses. (Worth, 1999)
While that is not a direct impact on nursing supervision, it certainly is an extended on. Not all states have taken measures to limit residents' shifts, so that all too many nurses still face the necessity of trying to give care when medical support for their tasks is absent or spotty. Needless to say, this will have an impact on the why and how of supervising nurses put in such a position.
Supervising today's nursing personnel
There are two main generation populations working as RN's today, Baby Boomers (born between 1946-1964) and Generation Xers -- GenXers (born between 1965-1975). Supervising effectively means understanding how to motivate and reward each generation, a role that's especially important in view of the abundant pressures described above.
Baby Boomers were born into a time of expanding U.S. wealth and they themselves expanded the economy more than any other generation. They also divorced more. GenXers are pragmatic,…[continue]
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