Nursing Leadership & Management in a Tertiary Care Hospital

Situational Overview

At a 300-bed suburban tertiary care hospital in the Chicago area, the new Chief Nursing Officer, Dr. M., has identified several issues requiring immediate attention. These issues have resulted in patient complaints, declining patient satisfaction scores, negative public relations, and deteriorating staff morale. The three major problems are: (1) excessive time for patient transfer from the Emergency Department to clinical units; (2) stagnant personnel and unit problems, including uneven workloads and care requirements; and (3) a lack of direction and a coherent customer care program, resulting in increased complaints across the board.

Dr. M. has sufficient experience in the medical field to understand the complexities of work units, fiscal responsibility, and employee development. She also recognizes that raising patient satisfaction scores is critical to the hospital's survival. However, because the hospital has operated for a century and has undergone dramatic changes over the years, change does not come easily to this institution's entrenched culture. This is true not only among staff, but also among many physicians, who operate on the paradigm of nurses as "doctor's assistants" — blindly following physician direction. Similarly, many Board members, managers, and 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 maintaining profitability. Change may be aided, however, by the upcoming retirement of the current CEO.

SWOT Analysis

Strengths: The hospital has been part of the community for 100 years, serving multiple generations. The community knows and trusts the medical care provided.

Weaknesses: Declining customer satisfaction is leaking into the media, resulting in community criticism and a perception that the hospital lacks focus.

Opportunities: There are considerable opportunities to partner with community and service organizations to enhance the hospital's image and involve the community in revitalization efforts.

Threats: Competitive pressures from other community-based healthcare centers are real; negative publicity may have driven some patients away, making it imperative to implement solutions quickly.

Strengths: There is a strong sense of camaraderie; most staff members know one another and have worked together for years.

Weaknesses: Morale is declining due to imbalances in workload, uneven allocation of expertise, and inadequate updated training.

Opportunities: Training programs and merit-based compensation will both boost morale and have a similar positive effect on customer service and staff expertise.

Threats: Some staff may be too entrenched and may require significant turnover in order to remove individuals who will not adapt to a new medical paradigm.

Strengths: The hospital is fully trained and staffed, with basic competencies maintained; at one time it was considered top-notch.

Weaknesses: Staff are firmly entrenched in old practices consistent with the institution's approach in the 1960s and 1970s.

Opportunities: An aggressive training program, combined with active recruitment from local colleges and universities, would provide a needed public relations boost as well.

Threats: Potential union issues may arise; some staff may resist professional development, and competing community hospitals may intensify their own recruitment efforts first.

Strengths: A comfortable, familiar schedule is currently in place and well understood by all staff.

Weaknesses: Imbalanced workloads are creating bottlenecks and reducing overall efficiency.

Opportunities: Revamping scheduling with a focus on client efficiency and care has the potential to improve morale and expertise by redistributing specialized tasks across shifts. Diversity initiatives, promotion from within, and an employee education program for additional certification are also viable.

Threats: Union issues, lack of available staff for needed procedures, and the inability to fund appropriate staffing levels could result in declining care and satisfaction ratios.

Strengths: Experienced physician staff are well-regarded in the community and have a well-developed sense of community both within and outside the hospital.

Weaknesses: Like the staff, many physicians have been employed at the hospital for decades and have formed their own entrenched networks within their group and with Board and upper management members.

Opportunities: Natural turnover may be positive; new physicians in their 30s and 40s may be attracted to a smaller community setting. Encouraging interns and exploring the potential of enhancing the hospital's reputation as a teaching hospital could bring new techniques and ideas to the organization.

Threats: Established locus of control, competition for institutional hegemony, and the comfort of current physicians within their roles pose significant resistance to change.

Strengths: The administration has demonstrated stability and obvious expertise in running the hospital for a century, along with strong rapport with community leaders and established partnerships.

Weaknesses: The administration is solidly reactive rather than proactive, mirroring the physician and staff situation with entrenched management and a lack of adequate foresight.

Opportunities: The retiring CEO creates an opening for a national search focused on a change management leader — not necessarily for the long term, but for a medium-term revitalization program that can shift the administrative paradigm.

Threats: Hospital reputation, time management deficiencies, and the challenge of moving from reactive to proactive operations are significant concerns; research is needed to establish how much market share has been lost.

Strengths: The hospital has a solid financial base; its building and overall debt ratio are low due to its longevity in the community, giving it the ability to weather economic peaks and valleys.

Weaknesses: The Board will need to be convinced of the necessity of investing more funding in new programs designed to increase efficiency and address customer care issues.

Opportunities: Reinvestment in technology, staff, and physical revitalization of grounds, rooms, and procedures all represent growth opportunities requiring additional capital infusion.

Threats: The Board may resist placing the hospital in a borrowing position; changing the face of the organization will require substantial capital, potentially necessitating additional investors and creative partnership or sponsorship opportunities.

Productivity Improvement Plan

The most essential immediate issue for Dr. M. is resolving the productivity problem regarding emergency department patients. The quickest solution is to meet with nursing staff, explain the seriousness of the issue, and outline plans for medium- and long-term solutions. Soliciting staff input and bringing everyone on board is critical — staff need to understand that negative publicity harms everyone. Working collaboratively, the team can revamp the schedule through a participatory management approach in which a flowchart of necessary procedures and staffing requirements forms the basis of group discussion. This plan should be implemented as quickly as possible and monitored regularly for feedback and adjustment.

Leadership Versus Management in Healthcare

Management and leadership are not synonymous, even if they are typically used interchangeably. This distinction holds true in business, education, and especially in healthcare. In general, a manager is someone who conducts and organizes affairs, projects, or people. Managers are granted authority by their organization to direct employees and therefore have subordinates. Even though managers are in charge, they are not leaders in the fullest sense of the term. Managers do as they are directed and, in turn, direct their subordinates. Management requires planning, scheduling, production, and adherence to time constraints; it is fundamentally task-oriented and often tactical, while leadership is strategic. In every field, leaders face new challenges in the 21st century — healthcare is no exception (Carroll, 2005).

Leaders do not have subordinates; they have followers. Leadership inspires, motivates, and sets direction to achieve goals, with a focus on people rather than tasks. Both individuals and organizations seek leaders: people want leaders to help them accomplish their goals, while organizations want leaders not only to motivate but to provide organizational direction. According to Kouzes and Posner (1994), five key behaviors define what people and organizations want from leaders: "(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, p. 960).

References

Carroll, T. (2005). Leadership skills and attributes of women and nurse executives: Challenges for the 21st century. Nursing Administration Quarterly, 29(2), 146–154.

Gershenson, Moravick, Sellman, and Somerville. (n.d.). Expert to novice: A nurse leader's evolution. Nursing Management, 49–52.

Kouzes, J., and Posner, B. (1994). An extension of the leadership practices inventory management system and individual contributors. Educational and Psychological Measurement, 54(4), 959–966.

Perra, B. M. (2000). Leadership: The key to quality outcomes. Nursing Administration Quarterly, 24(2), 56–61.

Vesterinen, S., Isola, A., and Paasivvra, L. (2009). Leadership styles of Finnish nurse managers and factors influencing it. Journal of Nursing Management, 17(2), 503–509.