Nursing leadership and management principles

Nursing Leadership and Management

Situational Overview -- in a 300-bed suburban tertiary care hospital in the Chicago area, the New Nursing Officer, Dr. M., notices that there are several issues required attention. These issues have resulted in patient complaints, declining patient satisfaction scores, negative public relations, and counterproductive and negative staff morale. The three major problems identified are: 1) Excess time for patient transfer from Emergency to Clinical Units; 2) Stagnant personnel and unit problems and uneven workloads and care requirements; 3) Lack of direction and a solid customer care program, resulting in increased complaints across the board.

M. has enough experience in the medical field to understand the complexities of work units, of fiscal responsibility, and of employee development. In addition, Dr. M. realizes that it is absolutely critical to bring up the patient satisfaction numbers if the hospital is to survive. However, because the hospital has been around for a century, and has undergone dramatic changes over the years, change does not come easily to the ingrained culture of the facility. This is not only true with the staff, but with many of the physicians, who operate on the paradigm of nurses being "doctor's assistants" -- period, blindly following their every whim. Similarly, many of the Board members, managerial cadre, and even administrative staff are part of the "old guard," and will require a soft-sell approach that reaffirms the hospital's commitment to the community while remaining profitable. The change may be aided, though, by the upcoming retirement of the current CEO.

Situational SWOT

Overall Issue

Strengths

Weaknesses

Opportunities

Threats

Community Perception

Hospital is 100 years old, part of the community for several generations; Community knows and trusts the medical care provided.

Declining customer satisfaction issues are now leaking into the media; resulting in community criticism and a perception of lack of focus on the part of the hospital.

Considerable opportunities to partner with community and service organizations to enhance the view of the hospital and involve the community in regrowth and regeneration.

Competitive pressures from other community-based healthcare centers; negative publicity may have driven some clients away; imperative to push a solution quickly.

Staff Morale

Strong sense of camaraderie, most staff know each other and have been working with each other for years.

Morale decreasing due to imbalance of workload, expertise allotment, and adequate updated training.

Two-fold; training programs and merit-based compensation programs will enhance morale and have similar positive effect upon customer service and expertise issues.

Staff may be too entrenched and may require a significant weeding out in order to rid the organization of naysayers or individuals who simply will not move into a new medical paradigm.

Staff Expertise

Fully trained and staffed hospital; basic level competencies; at one time, top notch.

Firmly entreanched in old ways and the ways the institution prospered in the 1960s and 1970s.

Aggressive training program; work with community and Board to actively recruit from local colleges and universities -- will also provide needed public relations boost.

Potential union issues, some staff may not wish to grow and develop; other community hospitals may increase their levels of recruitment prior.

Staff Scheduling

Comfortable schedule; everyone who works knows scheduling.

Imbalanced workload causing clogs in effeciencies.

Revamp with focus on client efficiency and care; has potential to increase morale and expertise based on spreading particular jobs to different schedules. Also explore diversity issues; promotion from within and an education program designed for employees who wish to gain additional certification.

Union issues, lack of available staff for needed procedures; inability to fund appropriate levels of care, resulting in declining care and satisfaction ratios.

Physician Issues

Experienced staff; well-thought of in the community; well developed sense of community both within and without hospital.

Like the staff, many have been employeed at the hospital for decades; they have developed their own cadre within their group as well as with members of the Board and upper level management.

Depending on age of staff, turnover may be positive; allow recruitment of new physicians in their 30s and 40s who might want to move to a smaller community; encourage interns, explore potential of enhancing reputation as teaching hospital (which brings new techniques and ideas to the organization).

Reputation within the medical field; establishment of locus of control; fight for hegemony; current physicians too comfortable within their roles.

Administrative Issues

Stability and security; obvious expertise in being able to run the hospital for a century; rapport with community leaders; trends and partnerships.

Solidly reactive rather than proactive; similar situation to physicians and staff; entreanched management; lack of adequate foresight.

CEO retiring; national search should find someone for change management role; not necessarily for long-term; but medium term revitalization program; with that comes paradigm changes for administrative staff.

Hospital reputation; time management; ability to move from reactive to proactive; research needed to establish how much market share has been lost.

Fiscal Issues

Solid base; building and overall debt ratio low because of longevity in community; ability to withstand economic peaks and valleys.

Board will need to be convinced of necessity to put more funding in new programs designed to increase efficiency and customer care issues.

Reinvestment in technology, staff, revitalization of grounds; rooms, procedures; all require additional capital infusion; opportunity to grow and prosper.

Board may not wish to place hospital in borrowing mode; changing the face of the organization will require large amounts of capital infusion. May require additional investors, potential creative or other partnership (sponsorship) opportunities.

Productivity Improvement Plan -- Clearly, the most essential issue for Dr. M. is a quick solution to the issue of productivity regarding ER patients. The quickest solution would be to meet with the nursing staff, explain the seriousness of the issue and the plans for medium and long-term solutions. Ask for input, get the staff onto the program so everyone understands that negative publicity hurts everyone. Work within the group to revamp the schedule and involve the staff in a participatory management program in which a flow chart of the necessary procedures and needed staff is part of the group discussion. Put into place as quickly as possible and monitor regularly for feedback.

Analysis - Management and leadership are not synonymous even if they are typically used that way. This is true in business, education, and in particular, in the health care field. In general, a manager is someone who conducts and organizes affairs, projects, or people. Managers are given the authority by their organization to lead employees, therefore, they have subordinates. So even though managers are in charge, they are not leaders in terms of the definition. Managers do as they are directed, and in turn direct their subordinates. Management requires planning, schedules, production, and time constraints; basically management is task oriented. The task orientation is quite critical -- management is often tactical, while leadership is strategic. and, in every field, leaders have new challenges for the 21st century -- healthcare is no exception (Carroll, 2005).

Leaders do not have subordinates, they have followers. Leadership inspires, motivates and sets the direction to achieve goals; leaders focus on people. Both people and organizations want leaders. People want leaders to assist them in accomplishing their goals. Organizations want leaders to not only motivate, but to provide organizational direction for employees to follow. According to Kouzes and Posner (1994), five key behaviors for what is wanted of leaders from both people and organizations are: "(a) challenge the process, (b) inspire a shared vision, (c) enable others to act, (d) model the way, and (e) encourage the heart" (Kouzes and Posner, 1994, 960).

The Contemporary Paradigm- in the modern world of nursing there are several aspects of nursing that require even more attention. First is the back to basics of healthcare and what the healthcare model should provide for society. Second is the responsibility of the nurse as a greater patient advocate. Third, something that rather we want to or not, must be a priority - cost control. The basics of healthcare are providing exemplary and compassionate care for all patients; regardless of income, ethnicity, insurance, language barrier, or age. In the late 1980s and 1990s, for instance, changes in the healthcare paradigm required nurses to become more specialized -- more distant from the patient, and almost as Physician's Assistants as opposed to Nurses. In fact, many scholars believe that the real key to quality outcomes in the entire healthcare industry, largely because of the unique position nurses hold, is new and bold nursing managers -- trained multidisciplinarily and able to handle multiple paradigms effectively (Perra, 2000). In fact, one of the best definitions of this new "person" is that "a nurse manager is a mosaic of many job descriptions, which often includes human resource expert, business manager, risk manager, therapist, and clinical expert" (Gershenson, Moravick, Sellman and Somerville, n.d., 51).

Modern healthcare is a rewarding, but challenging, career choice. The modern healthcare professional's role is not limited to only assisting the doctor in procedures, however. Instead, the contemporary professional takes on a partnership role with both the doctor and patient as advocate caregiver, teacher, researcher, counselor, and case manager. The caregiver role includes those activities that assist the client physically, mentally, and emotionally, while still preserving the client's dignity. In order for one to be an effective caregiver, the patient must be treated in a holistic manner. Proper communication and advocacy is another role that the modern caregiver assumes when providing quality care (Carroll).

It is in the role of patient advocacy and cost-cutting that most nursing leaders are directly involved with hospital policy. Technology has increased the ease and ability for adequate communication -- there are more translators, access to databases, etc. within the field, and certainly there is more information about healthcare available for the layperson. However, the manner in which modern medicine works -- the reality that it is the nurse as opposed to the doctor who tends to follow the patient throughout their care, lends greater credibility to the use of the modern nurse as a paradigm for successful communication and patient advocacy (Vesterinen, Isola and Paasivvra, 2009).

However, the realities of contemporary medicine always involve costs. Nursing leaders show that it is the responsibility of everyone involved in healthcare to help find ways to streamline procedures, waste less, and as part of the advocacy model help keep costs down by limiting excessive procedures whenever possible. Hospital care is certainly necessary, but also, in many circumstances patients do better released into their own, comfortable environment as quickly as possible. To that end, many nurse leaders believe that the United States homecare nursing professionals are both underrated and underutilized.

Clearly, each of these issues has a direct effect upon Dr. M's ability to recommend and effectively institute change management within this organizational structure. For instance, in Dr. M's previous situations, the locus of control for professional nurses allowed for management of patients on a 24-hour rotation; with each shift being responsible for their own particular patients. However, Dr. M. is aware that a professional nurse management staff has additional fiscal requirements that must be Board approved. There are, however, a number of additional ways that funding can come into the hospital to professionalize and improve issues identified within the SWOT.