Reflection on Demand and change in Nurse Manager

Over the last decade management in nursing has become increasingly demanding (Hyrkas et al 2005). The role of nurse managers has undergone significant change as nurse managers have taken on more administrative roles. Restructuring and specialization of healthcare organizations has had an impact on the role of the nurse manager. If preparation of nurse managers is inadequate, potential for role confusion and role stress increases, undermining role effectiveness in this key position (McCallin & Frankson, 2010). Within the hospital and specialized clinic setting a synergy between business practice and clinical practice is vital to the success of the organization. In my experience as a nurse manager, while attending monthly management meetings, I have experienced hospital administrators (CEO’s and CFO’s) that understand that nurses are essential for a hospital or health clinic to function, and to maintain a high quality of care. But at the same time these administrators express concerns that department managers are not as responsive as they would like in relation to alignment with organizational resource management and objectives. In these instances it appears that the administrators and department managers are out of “sync” in what they understand the job role to be. This perception does not negate the clinical expertise of the manager but may demonstrate a lack of business skill, or understanding of the business objectives and expectations of the role for the clinical manager. Healthcare is a business and, like every business, it needs good management to keep the business connected and running smoothly.

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The aim of this paper …..As part of my personal development plan, using the example of cardiac care clinics, role challenges are discussed, and implications for nursing management that present a new approach to nurse manager development I will explore the challenges that face nurse managers to better understand the integration of business expectations and the role of the nurse manager in the setting of cardiac care and identify possible improvements that could close perceived training gaps being experienced. I see this knowledge as being helpful in my personal development but also in developing templates to assist other managers to improve as they embark into managing specialty clinics.

Healthcare organizations are working to provide optimal care in cost effective ways. The tension between these two objectives is challenging for all levels of management. In my experience with cardiac care, I see nurse managers being challenged to develop optimal planning algorithms, patient satisfaction surveys, or building new clinical paths, such as cardiac care service lines for focused cardiac management. Choices ultimately have to satisfy clinical objectives of optimal care, outstanding communication, collaboration and transparency of information. At the same time organizational issues need to be addressed in order to deliver products and services in a sustainable way (cost effective, evidence based, and state-of-the art). Nurse Managers are required to become experts in the fundamentals of business management which often is beyond the education and experience of a registered nurse (Wright, Rowitz, & Merkle, 2000) (Mathena, 2002) (Douglas, 2008). To address these concerns within the setting of a specialized clinic, specialized training and support could be designed to develop the skills and models to support the development of effective nurse managers.

As nurses, much of how we learn to manage and lead is learned informally as we advance in our careers. However, this does not mean that it cannot be done better. Management skills may be learnt on the job but are also skills that should not be left to chance. The gap in management and business preparation among nurse managers is an area that could be improved (Noyes, 2002). One argument is that these skills are acquired in the “University of Life” (Pedler, Burgoyne, & Boydell, 2007, p. 13). Education and support of clinical nurse managers received considerable attention in the 1980’s, with accounts of preparatory courses which were considered to have been effective at the time (Gould, Kelly, Goldstone, & Maidwell, 2001). In the years since much has changed in healthcare.

Continuing ill preparedness for nursing management and leadership continues to be documented (Douglas, 2008). As the span of the role has expanded, nurse manager workloads have increased (Lee & Cummings, 2008). This can lead to role fatigue that threatens individuals, the role itself, along with the clinical objectives of the cardiac program. The situation is sustained when nurses are promoted into management roles without any formal management training at all (Platt & Foster, 2007). In my experience, the cardiac specialty clinic has intense challenges; the scope of the role is wide-ranging. A nurse manager enters a cardiac specialty role with advanced clinical expertise and must promptly become a strategic planner, human resource authority, quasi-business manager, financial analyst, risk manager, operations manager, quality specialist, and clinical expert (Crowther, 2004). Other competencies include staffing management, performance evaluation, team development, delegation, conflict resolution, change management and problem solving (Mathena, 2002). Research suggests that nurse managers receive little management support and little is done to set expectations, track performance, or offer feedback (Tuglan, 2007) Poor access to formal organizational support suggests that a nurse managers management skills are learnt utilizing trial and error methods (Paliadelis, Cruickshank, & Sheridan, 2007)

To better understand the integration of business expectations and the role of the nurse manager in the setting of cardiac care, I conducted semi-structured discussions with key stake holders and support experts (CMO, CFO, DON, Purchasing Manager, and Nurse Managers). With the permission of the individuals I documented field notes to later review and analyze systematically, to identify recurrent themes and understand perceived gaps existing between the clinical and the business aspects of management within the specialized cardiac clinic. A simple thematic approach was utilized where the notes were coded according to similarities and differences that were grouped into categories and then arranged into themes. Three themes emerged from the notes namely, understanding of the managerial role, management and business training deficits, and a general feeling of management overload.

The discussions were structured based on clinic management, operational management, value proposition, market segment, strategic position, and clinical strategy. This structure provided a framework to categorize the differing responses to identify the applicability of clinical and business theory to establish a clearer understanding of the elements required to build a nurse manager development strategy.

In understanding the cardiac clinic manager’s role, administrators acknowledged “Within the cardiac arena, healthcare knowledge that nurse managers must possess has changed and continues to change dramatically, these changes are more complex, frequent and rapid than ever before” CEO.

The clinic managers themselves identified a lack of clarity; comments indicated that the manager’s role is diverse when compared to the job description.

“Within the cardiology specialty, the cardiac managers role has become more challenging today than in the past, mainly due to the numerous changes that are occurring in cardiac care today” Cardiac Clinic Manager.

The lack of preparedness for the role was an area that reinforced what the literature stated. Common comments included:

“Not all nurse managers are successful in the transition from staff nurse to management. The successful nurse managers achieve results through their ability to develop leadership skills, critical thinking skills, and over time, a development of mutual respect.” Director of Cardiac Services.

“I was the go-to person for the cardiology step down unit; I had good clinical skills, and was promoted into a management position. You could describe my transition as baptism by fire” Cardiac Clinic Manager.

When asked what a successful nurse manager would look like, the majority of answers indicated that success was interpreted as maintaining staff satisfaction, avoiding patient complications, and dealing with the day to day problems associated with the patient flow through the clinic. Integrating specialized cardiac clinical experience with management skills is identified as challenging, management role descriptions need to be supported and aligned with organizational objectives. I see this as having implications for the development of cardiac clinic nurse managers because if roles are vague managerial communication and leadership will be challenging.

The second theme evident was a business management deficit. Business and financial management was identified as being an area of nurse management that made the role demanding. As a manager I have had to manage information technology, finances, human resources, business strategies and organizational operations. This is a very wide subject potentially requiring knowledge of many aspects of business as it relates to, health economics, quality, value, reimbursement, and strategy. Although some nurse managers identified a familiarity with budgeting and performance improvement, they also expressed that these were areas that they had no formal training, and that were viewed as outside of their control.

“There was no formal business training. My problems are figures, budgets and reports. I was completely computer illiterate, and am not much better today” Clinical Manager.

Situations were also described where nurse managers don’t speak up, or attend organization planning, or strategy meetings, and as a result the organization bypasses them when making key decisions. Nurse Managers are not taught how to influence business practices within a healthcare organization.

“Many clinic nurse managers don’t seem to take ownership of the operational management of their departments” Purchasing manager,

Several hospital administrators identified that the Nurse Manager are rarely considered experts in the logistics associated with the supply, operational, and fiscal management. Administrators agreed that nurse managers have a difficult position, in that they have 100% accountability for quality care, and productivity within the specialized clinic, but not 100% authority. Connecting the clinical aspect of cardiac services to funding is essential for financial managers to select appropriate working capital strategies to support the overall business strategies and objectives (Marsh 2009).

As I consider the nurse manger’s role in today’s specialized healthcare environment, it is important to place the subject into context of what has happened – and what is happening in our field of work, because managers in today’s cannot simply emulate managers of the past (Ellis, 2005, p. 3). Key stakeholders (administration, CEO, CFO) interviewed identified that trends in cardiac healthcare are being affected by such things as: the global market place, the impact of information technology, demands for higher quality and faster service, shorter implementation times on healthcare initiatives, increasing specialty focus and disease management customization, external relations: consumers and industry. High expectations challenge managers asked to stretch resources and time beyond what can be effectively managed. Managers speak of feeling overwhelmed. Common comments included:

“There are not enough hours in the day, to complete the report, budgets, planning and meetings” Cardiac Service Line Manager.

And

“It’s about what is achievable and what is not – you have to deal with it” Cardiac Clinic Nurse Manager.

Quality management was a phrase that was identified by all, and appears to be a priority in today’s healthcare arena, describing a level of management or service. Some philosophers Plato 2500 years ago to Robert Pirsig in 1975, in Zen and the art of motorcycle maintenance, argue that quality cannot be defined, that we just know it when we see it. In striving to provide, and document proof of quality services nurse managers are pressured to manage and identify the key performance indicators that would be most valuable and then report formats that would be most useful to users, all with little or no training in this area.

The role of today’s specialized healthcare manager is seen as even more complicated due to the rapidly changing environment surrounding cardiovascular services. Literature supports the fact that managers of previous generations did not have to deal with the rapidity, complexity, and frequency of change that managers are faced with today (Ellis, 2005, p. 13). As new management roles are created, in response to change, the clinician, transitioning to management must give up their role as an individual contributor. As an individual contributor success is measured by the accomplishments of the individuals work. As a manager, you are no longer responsible for what you alone accomplish. You must now work with your direct reports to achieve the goals of the department and the organization.

Specialized clinics should not have to reinvent the wheel, with the adoption of methods, tools and techniques the specialized clinic could evaluate current strategy and test future scenarios. There must be a perceived need for change with decision makers. During informal field discussions I discovered many instances that indicated a need for change as well as the need for inclusive ways of framing seemingly complex problems. This was verbalized through feelings of frustration and inadequacy; these situations could be categorized as general inadequate knowledge and preparation.

Understanding the role of the manager, is important and in broad terms, I see this as achieving results through, and with others, to help their healthcare team be productive and effective in providing quality care. To do this, competencies such as guiding, supporting, and development of others to higher levels of performance are needed.

“Managers need to create an environment that encourages and motivates individuals to perform” (Chief Nursing Officer)

When you create the right environment, achieving results through others becomes much easier. (Boyette & Conn, 1992)

Data from the interviews indicated that clinical nurse managers appeared to feel clinically competent but generally experienced lack of concordance when dealing with a range of issues, in particular; human resources, managing budgets, communicating at a business level and using information technology in everyday practice. The most effective nurse managers are identified as those who accept full accountability for their own training and development within the clinic and for the outcomes that the clinic achieves.

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This paper has attempted to explore the issues affecting a nurse manager, specifically as it could relate to a specialized clinical area. I have found that the need for educational support is compounded by a business management deficit and high expectations (possibly unrealistic) that may be causing work overload among nurse managers. It can be stated that the nurse manager role encompasses both management and leadership, and that managers are appointed without the essential organizational management skills or support, making these managers vulnerable in their positions. Obtaining, training, and retaining nurse managers who have the skills and knowledge to manage specialized cardiac clinics is extremely important. Management development is a highly necessary pursuit (Tanner, 2002) (Srsic-Stoehr, Rogers, Wolgast, & Chapman, 2004) for nurse managers to assist in addressing the challenges in their positions.

Drucker 1967 on developing managers believes that development is not about identifying talent for today’s requirements, but it should embrace developing managers to manage the future. It is important to ensure that a policy of developing the management and leadership potential in all and particularly of newly appointed managers. Individuals should also ensure that they focus on developing their own management skills through training, reading, analyzing, and following the example of good managers and by assessing, monitoring, and improving their own performance. The best managers increase the health of the workers whom they manage (Maslow, 1998, p. 94). There are a number of possibilities in up skilling nurse managers, self development or personal development, with the nurse manager taking primary responsibility for their own learning and for choosing the means to achieve this. Ultimately it is about increasing your capacity and willingness to take control over, and be responsible for, one’s own development. Self development can mean many things, developing specific qualities and skills, improving performance in your job, advancing your career or, achieving your full potential as an individual. The question here is can an individual be willing and disciplined enough to identify and complete the ambitious goals that would be required here?

There are many suggestions in the literature that guide and recommend models and methods to train and develop nurse managers; one suggestion is to develop in-house leadership through a Nurse Leadership Academy, as outlined in appendix II. Once a hospital initiates this kind of program, it can expand it to other leaders in the organization, and also begin developing an internal cadre of coaches and mentors.

It has been suggested that one way to manage and assist the specialized cardiac clinic organizations improvement process is by implementing concepts such as Lean Six Sigma to improve performance, core process or quality service (Womack and Jones 1996, 2005). These programs assist in organizational development but not the individual. Six Sigma courses are designed to teach employees and management ways to eliminate wasteful processes, automate processes, minimize error and better utilize resources. Training of managers in Lean Six Sigma can facilitate positive change but the process has also been likened to trying to build a plane while trying to fly in it.

There have been many suggestions on training needs for the nurse manager, from information gathering and design specific programs to meet areas of concern such as communication, finance, information technology, leadership and quality, to subsidizing formal academic education through higher education, but sometimes these pathways are over engineered and do not designed with a supportive structure that facilitates practice adoption. Higher education is essential for managers to further branch out and develop professionally, programs such as MBA’s, Informatics, Masters programs in hospital administration offer much opportunity, but are also often not supported or backed up with mentoring programs and resources from within the managers clinical workplace.

Passionate as I am about the potential contribution of specialized cardiac care programs and management education of the “leaders for tomorrow”, I remain convinced that a supportive approach is the foundation within this specialty area. In the foreseeable future specialized clinics are going to own the problem of training and developing managers, a component of this will involve support and encouragement of nurse manager personal development, with the nurse manager being encouraged to take primary responsibility for their own learning. Tertiary healthcare education programs, rightly or wrongly, are not about to relieve healthcare of this burden – or, I should say opportunity, but has the potential to support an individual’s quest for professional development as a manager. Much of this can be supported with the initiation of individual development plans IDP’s (Appendix III).

This is not what I had envisioned as I started this evaluation looking into new approaches to nurse manager development and education. I see that a personalized approach is needed for both my own development and the development of other managers; the approach would not necessarily incorporate a generic formalized education plan, but would encourage the goals, with the support of organizational resources, backed up by an E-learning capability and personal mentor.

I see clinical management in specialist centers is not merely for the intellectually curious. Management should be for those who are not content to follow, for those who believe that the best way to win is to rewrite the rules, for those who are unafraid to challenge orthodoxy, for those who are more inclined to build than cut, for those more concerned with making a difference than making a career, and for those who are absolutely committed to staking out the future first. David Roffe the CIO of St Vincent’s Hospital group in Sydney identifies the goal for managers may be identified as enlarging their personal development to fully encompass the emerging healthcare reality.

Appendix I

In many instances a cyclic self evaluation has us going back to evaluate how to move forward.

Boydell 2003 doing things well, doing things better, doing better things, Sheffield interlogics

Appendix II

Nurse Leadership Academy Outline

The program could include but is not limited to the following elements:

1. Selection of high-potential candidates. Many hospitals start with the existing Nurse Managers to create a common language and way of thinking about leadership. Then they involve a second group of high-potential Assistant Nurse Managers and Staff Nurses.

2. Initial welcome, orientation, and content delivery. A two or three day retreat grounds participants in the key elements of being a successful leader in the hospital. At the same time, participants choose ambitious goals to improve quality, service, and cost at the organization. Note that time must be reserved to prepare for this retreat. For instance, we will assess an organization in order to tailor our existing Nurse Manager’s Performance Leadership Program to the specific needs of the organization. Also, we will work with leadership to determine key areas for improvement.

3. Monthly follow up meetings to discuss progress on goals, hear presentations from hospital leadership (e.g., a board member might discuss the role of the board), and learn additional content.

4. Ongoing one-on-one coaching as needed.

5. Some form of recognition after a year.

Appendix III