Issues as a Nurse Manager: A Comparison of Two Case Studies - Research Paper Example

Issues as a Nurse Manager: A Comparison of Two Case Studies Introduction Nurse managers face the daily daunting task of coordinating and managing the daily operations of the nursing staff. They are also in charge of recruitment, staff retention, and of maintaining the quality of patient care. These responsibilities are now coupled with various problems and issues in the nursing profession. Issues like staff shortage, budget constraints, policy changes, and supply shortages make the nurse managers’ role challenging and complicated. Nurse managers deal with these issues in different ways, applying various management and problem solving techniques. This paper shall discuss two cases of nurse managers and the issues and problems they encounter in their practice. This paper shall study two cases: one, in the United States and another one in Australia. It shall compare and contrast issues encountered and how nurse managers deal with and resolve these problems and issues. Review of Related Literature Various studies have examined and documented the different issues encountered by nurse managers in the nursing practice. These studies have exhibited that nurse managers often face problems related to nursing staff shortage. Shortages in the nursing profession eventually affect the mental and physical health of nurses. And the dangerous point about having stressed and burned-out nurses is that, the quality of patient care is also affected. A study reviewing the general nursing shortage in the United States revealed that four areas contribute to this nursing shortage and these are: aging of the RN workforce, decline in nursing student enrolment, changing work climate, and the poor image of nursing (Goodin, 2003). These problems have made it difficult for various nurse managers to assign an adequate number of nurses to care for the overflowing number of patients in the hospital’s care. Many hospital administrators and even nurse recruiters emphasize that this shortage of nurses has been going on for far too long. “The long standing US nurse shortage has led to chronic understaffing that can threaten patient care and nurses’ job satisfaction, and the problem is expected to worsen” (RamDe, 2009). Even with various incentives for nurses to enter and to stay in the profession, the turnover for nursing staff is still much too fast and much too frequent. Nurse managers are often faced with the dilemma of having to continually set aside increasing amounts of finances in order to cover for the training of new recruits who may just leave after a year’s work. Qualified trainers are also hard to come by in the nursing profession; there is also a shortage of nurse educators, hence a shortage of nursing enrolees. Nurse managers are also faced with the challenge of coming up with ways of retaining their original staff members who already have undergone the necessary training needed by the hospital. Another research has revealed that some of the issues faced by nurse leaders relate to the present focus on specific standards of care, not anymore on the process of caring for the patient. There is also a growing focus on federal reporting of patient satisfaction. These changes “represents explicit accountability for managing and leading the staff responsible for providing the patient care” (Thompson, 2008). These safety and patient satisfaction reports have great weight in acquiring federal funding and government support. This puts too much pressure on nurse managers and nursing staff to attain patient satisfaction. But the attention is not placed much on the importance of the nursing process. Similar results were revealed in an Australian study which indicated that there are different barriers to clinical leadership that preclude nurse managers from making effective and properly informed decisions. These barriers share similarities with previous studies which also relate to nursing shortage, budget constraints and absence of properly evaluated models of care (Davidson, 2006). Budget constraints tie the hands of administrators. It precludes them from acquiring and delivering the best possible care they can give or buy for the patients. The present global economic crisis has not spared the healthcare industry which has suffered budget cuts in government allocations. These budget cuts and constraints have forced nurse administrators to reduce hiring of additional and adequate staff to meet the growing needs of the general population. It has also limited their ability to acquire adequate and improved medical equipment to make the jobs of nurses easier and more efficient. These budget constraints have also prevented nurse managers from offering better pay for overworked nurses – motivation which would have prompted many of these nurses to stay and not to opt for career changes. And because of ever-increasing budget cuts, nurses are overworked, underpaid, and eventually they opt for career changes. Nurse managers are again left with the burden of finding and training new nurses to fill in these vacancies. Again, money is spent for these trainings and the already financially strained hospital budget is further stretched and strained. Another study also revealed that budget constraints have drastically affected position allotments in nursing staff positions. In Australia, rural hospitals were able to lure more nurses through higher salaries, which now shifted the problem to nurse managers in the urban areas who have lost many of their nurses to the rural hospitals (LaSala, 2000). Many of the problems faced by nurse administrators can be traced back to budget and financial constraints. Budget constraints have forced nurse managers to limit their hiring and their recruitment of nurses; it has also prompted them to limit training for new recruits. As a result, many nurses are not competently keeping up with new and innovative medical techniques and procedures. And yet, “the demand for skilled nurses has increased with advances in complex health care and technological services available in the health care settings” (LaSala, 2000). And still, nurse managers have difficulties in actually meeting these demands from the patients because of budget constraints. Constant changes in health and nursing regulations also cause various coordination problems for nurse administrators. They often opine that the changes in reporting requirements are all too frequent and it is becoming difficult to keep track and to comply with these constant adjustments and changes. Various health experts emphasize that nurse and hospital administrators have to constantly update themselves to these regulatory changes because these changes update the quality and the standards of care being rendered by hospitals and healthcare professionals. Nurse and hospital administrators need to constantly monitor these regulations in order to bring up to date the overall condition of the organization. And this necessarily includes constantly updating and retraining the healthcare staff. “Employee response is the ultimate test of facility compliance with required standards, so education of staff and physicians must be vigorous and ongoing” (Burden, et.al., 2000). Some nurse administrators may take issue with constant changes in regulations, however, they need to understand that the healthcare industry is constantly redefining itself. Hence, these changes in regulations are needed in order to ultimately benefit the ailing patient and the healthcare industry. Various solutions to these issues have been adapted by nurse managers. A study revealed that some nurse managers attempted to solve the nursing shortage issue by exploring recruitment and retention efforts, improving the image of nursing, and supporting legislation that helps rectify the shortage (Goodin, 2003). These solutions focus on how to improve recruitment techniques in the hiring of nurses. Nurse managers have gone to great lengths to entice applicants and even enrolees in nursing education. Some of their efforts have paid off but, they eventually faced the challenge of how to keep these nurses in the profession. Nurse managers have increased salaries and incentives for nurses, however, they eventually had to limit such increases due to budget constraints. In the end, the nurses are still overworked and underpaid and they eventually opt for career changes. And “when staff is short the problem falls squarely on the shoulders of the nurse manager who is expected to cover the unit even though there are inadequate bodies to do so” (Wieck, 2005). Similar studies indicated similar solutions which again can be traced back to budgetary concerns – concerns that the nurse manager has limited control over. This paper shall use a minimally structured interview in order to gather information from primary respondents. Questions related to the primary functions of the nurse respondents shall be included in the questionnaire. Problems and issues related to the respondents’ roles as nurse managers shall comprise the bulk of the questionnaire. This type of questionnaire best fits this paper because it will help establish vital information needed for this research while allowing the respondent the freedom to elaborate on her answers, and also allowing the interviewer the chance to ask follow-up questions pertinent or related to the topic at hand. Results of the U.S. case The nurse manager from the United States is responsible for a free standing ambulatory surgical centre which performs approximately 3,600 procedures each year. She manages 18 full time equivalents, with a mix of full-time and PRN employees. The centre is manned by 5 employees in the business office (receptionist, business office manager, biller, collector, and an insurance verifier/medical records coordinator). The centre also has one nurse manager, four registered nurses for their pre-post area, three registered nurse circulators and four operating room techs. One of the OR techs also functions as the materials manager in charge of inventory management as well as the ordering and receiving of supplies. They also have one registered nurse who contacts every patient prior to surgery to evaluate them for appropriateness to the outpatient setting and to give the patients instructions prior to surgery. And finally, there is the administrator. The nurse administrator interviewed for this paper graduated with an Associate Degree in 1978 which she later capped off with a Bachelor’s Degree in 1992. She has had extensive experience as a nurse in fields of surgery, labour, delivery and neonatal intensive care. After she earned her Bachelor’s degree she was promoted to a manager’s position for a Women’s/GYN unit. She also managed an LDRP for two years before moving to Florida to work at an LDRP/Paediatric and Women’s Unit at a private hospital in Sarasota. She later became Program Manager for a Wound Care Centre for 3 years. She has been in her current position as administrator for a surgery centre for the past 10 years. The nurse administrator cites three main challenges which she faces today in her attempt to balance organizational requisites, safety, and customer (internal/external) demands. These challenges are: keeping up with changes in regulation requirements, time management, and the ever increasing rising cost of supplies. She illustrates that in the free standing ambulatory setting where she works, she often needs to wear many hats. The centre does not have an on-site plant operations supervisor, a human resource department and customer liaisons officer. Because of staff these deficiencies, she often finds it difficult to manage the daily needs of the centre at the same time keep up with the schedule of regulatory requirements pertaining to the building (i.e. generator, fire sprinkler, and biomedical inspections). She also cites that nursing in the ambulatory setting has changed as regards the amount of paperwork required by various regulatory agencies. The centre now tracks and trends more data than it used to. Examples of these data include: wrong site surgeries, IV antibiotic prophylactic administration, falls, hospital admissions, burns, infections, medication administration errors, and similar information. She sees a variety of problems that the centre will face within the next five years or so. She indicated that one of these major challenges would be on how to increase the volume of their procedures. The centre has a limited amount of surgeons and is currently competing with two other surgery centres in the area. These other centres are constantly trying to recruit their surgeons. The competitor centres are 100% physician-owned, whereas the centre is a corporate-owned business with physicians as limited partners. The benefits to the partners are limited risk and liability as well as access to excellent insurance contracts. By increasing the volume of their surgeries, their physician partners would be better motivated to stay with the centre and to enjoy the return of their investments. In order to competently deal with problems in nursing shortages and staff retention, the centre and its staff only works during weekdays (Mondays through Fridays) with weekends and holidays off. There is also no shift work and therefore, the centre and the nurse manager has had little difficulty in recruiting and retaining their employees. The centre also remains competent with the market in terms of salaries for its staff and PRN employees. The employees in the medical centre expect honesty and fairness in their nurse manager/leader. She indicated that she does not have any problem with these expectations and in fulfilling and applying them in her life and in her practice. She indicated that her employees would most likely describe her management style as hands-on, fair, and open to communication. She is also confident that her employees will describe her as someone who meets the needs of the organization while considering her needs as well as the needs of her employees. Results of the Australia Case In the Australia case, the nurse manager occupies the position of Director of Clinical Services in a private acute care hospital. She is responsible for mixed services of surgical, day surgical, and obstetrical care. She manages about 1,800 employees including hotel services, division 2 registered nurses, division one registered nurses, midwife and support clerical staff. She has a Master’s degree prepared in Health Care Management and many years of service in the public sector as a nurse manager of obstetrics/labour and delivery. She served as director of clinical services at Frances Perry for 5 years and has now served her present position for 10 years running. The challenges she faces today in her attempt to balance organizational requisites, safety, and customer (internal/external) demands are the following: unrealistic staff expectations of lower nurse/patient ratios, resistance to change in care models, budgetary constraints, and staffing shortage. In describing changes she encountered in the past ten years as a nurse manager, she described that previously, as a nurse manager, her responsibilities were task focused – mostly related to staffing, making the payroll, and daily support of her specific units. Today, she noticed that as a nurse manager, she is not required to take ownership and fiscal responsibility for the units. Before, as a director of clinical services, her responsibilities focused on the hospital itself, and now she noticed that there is a greater involvement in strategic planning as well as the healthcare system. There is also a greater call for involvement and knowledge of the outside world, as well as projecting possible changes that may come from the administration. She expressed that possibly in the next 5 years, the major challenges that her healthcare organization will face would relate to meeting consumer (internal/external) demands while providing quality care in an environment which is unstable and in which the healthcare dollar stretches less. Some of the strategies she is putting into place in order to deal with staffing shortage and to promote staff retention in her area are the following: setting up staff forums to give a medium for the staff to voice their concerns; educating departmental managers in change management strategies and educating them in new models of care. She chose nursing management as a chosen field because she was encouraged by a former Director of Nursing when she was herself a nurse manager in the public system. The director recognized her skills and her potentials. The Director also encouraged her to obtain her master’s degree and actually began to groom her for the role which she now holds. She says that the employees under her management seem to have their own idea of what qualities a nurse manager should embody, she further indicates that, these days nothing seems to satisfy employees when it comes to leadership qualities. Discussion The two cases illustrated above have similarities and differences. They portray similar issues in nursing administration and management. In the Australia case, the manager indicated that nursing shortage and budgetary constraints are vital issues in the healthcare setting she works at. As was mentioned and illustrated by the review of related literature, these are problems that eventually affect the quality of health care services because they cause much stress and burn-out for nurses. In a recent report, about 80% of nurses acknowledge that the shortage ultimately impacts the quality of care they render to patients (Medical News Today, 2009). They emphasize that their numbers are dwindling, they are overworked and underpaid, and the nurse/patient ratio is overwhelming for nurses and unhealthy for patients. Statistics have also revealed that between 2004 and 2014, about 1.2 million nursing positions will be needed in order to meet the growing demand for new nurses and medical care. Budgetary concerns are vital issues for both nurse administrators. These budget concerns are similar with revelations from studies reported in the review of related literature. Budget concerns ultimately affect the hiring of new nurses, acquisition of new and updated medical equipment, salary increases for nursing staff, and the training of new staff. These similarities in issues indicate that the nursing shortage and budgetary concerns are not local or isolated concerns, in fact, they are presently global issues. The way each administrator deals with the problems and issues are very much different. The American administrator does not have much problem in dealing with the nursing shortage because the centre only caters to patients during weekdays and there are no shift changes in the centre. The salaries of the staff also competently keep up with the expected market wages. In the end they do not have much trouble retaining their staff. In the Australian setting, with more employees on staff, and with more patients to care for, the nurse administrator considers staff shortage a problem in the hospital. She opts to deal with these problems by giving the employees a venue to express their concerns. Her approach in dealing with the problems is by giving the employees a chance to be heard. By opening the lines of communication, the nurse administrator has a good chance of retaining the staff. And the nursing staff knows that solutions to their concerns can be addressed and formulated by the administration. Some studies have proposed various solutions to the nursing shortage. These solutions include salary incentives and increases and making the work environment more attractive to nurses. However, it is the financial incentives which entice many nurses to stick with the profession. And many hospitals in the States are acknowledging incentives as viable solutions to the nursing shortage problem. In fact, “many hospitals are paying nurses signing bonuses of $1,000 to $5,000 or more and are temporarily filling vacant positions with registry or travelling nurses” (Steinbrook, 2002). Other incentives include salary increases ranging from 18 to 23 percent over a period of 23 months. Hospital administrators understand that in order to win the battle against the nursing shortage, there is a need for them to help ensure that nurses have more stability in their financial status, and for their long hours to be adequately compensated. Offering financial incentives is not as simple in some parts of Australia because of government regulations on wages. Nurses in Victoria, Australia are currently among the lowest paid nurses in Australia because of lower wage rates prescribed by Victorian officials. In recent years, Victorian government officials have managed to make adjustments in the wages of their nurses in order to retain their workforce. And it is important to point out though that, Victoria is the only area in Australia which has actually set a minimum nurse/patient ratio. “Now it is time to work on Victorian nurses’ wages to ensure nurses who have been recruited into a system where they work with safe mandated staffing levels are paid what they are worth and not lured away by more attractive wages in other states” (Australian Nursing Federation, 2008). The Australian hospital also makes mention of the fact that they conduct training for their staff in order to update the latter about the changes being undertaken in the nursing profession. These trainings are not mentioned by the American administrator. The Australian administrator recognizes the need to train and educate the staff and the employees, whereas the American administrator does not seem to see this as much of a concern for their employees. Training staff about new policies in nursing in the medical and health care profession is an important part of nursing and of healthcare. It is important for nurse administrators to recognize the importance of training and continuing education of their nursing staff. Skills need to be updated in order for the nursing profession to keep up with the changes in the healthcare industry. And “although many standards of care are well defined and long standing, new standards are regularly being formulated to address changes in the practice of nursing” (Gaffney, 2001). The American administrator indicates that their centre may be dealing with an increase in the volume of their surgeries within the next 5 years. These concerns are similar with the Australian administrator who also indicated that there may be increasing customer demands within the next 5 years. The Australian administrator also emphasized that budgetary concerns will continue to escalate within the next 5 years. The American administrator did not make mention of future budgetary concerns. This may be because, at present, they seem to be operating within acceptable financial limits. The American administrator seems to have an open and honest relationship with her employees and staff. She indicated that she was comfortable with her employees requiring honesty and fairness in her work as their administrator. The Australian administrator is not too obliging about assessing her leadership qualities in relation to her employees’ viewpoints. Her disposition may be understandable considering the fact that she is dealing with more employees than her American counterpart. She also has more budgetary and staffing concerns as compared to the American administrator. In retrospect, she herself may be suffering the emotional and psychological impact of limited staff and she may be reflecting the stress and burn-out of overworked nurses. Conclusion The two cases discussed above indicate that nursing shortage is a global phenomenon. This shortage is also aggravated by the present economic crisis that plagues many countries of the world. Nurse administrators have to deal with this nursing shortage and budgetary concerns alongside countless adjustments in the healthcare system. These administrators deal with these problems by applying different techniques that ultimately affect the way they relate to their employees and the way their employees perceive them. The nurse manager is often required to perform different functions and to wear different hats depending on the problems and issues that come up in the organization. And these different roles call for various leadership and management styles on the part of the nurse manager. Some techniques may work in some instances and for some subordinates, and these same techniques may not work for others. However, the most important thing that the nurse manager should remember is about being true to the profession and to the core principle of the healthcare industry, and that is, to FIRST, DO NO HARM. Works Cited Burden, N., et.al., Ambulatory Surgical Nursing. USA: Elsevier Health Sciences. Davidson, P. Clinical leadership in contemporary clinical practice: Implications for nursing in Australia. Journal of Nursing Management. April 2006. Volume 14 (3): 180-187 Gaffney, T. Regulation of Nursing Practice. Nursing World. 2001. http://www.nursingworld.org/mods/archive/mod310/cerm102.htm (accessed 06 May 2009) Goodin, H. Integrative Literature Reviews and Meta-Analysis: The Nursing shortage in the United States of America. 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January 9-15, 2009 http://www.asianjournal.com/pdf/PDF/2009_SF/2009_01_09/2009_01_09_SF_A%204.pdf (accessed 06 May 2009) Steinbrook, R. Nursing in the Crossfire. New England Journal of Medicine. 30 May 2002. http://content.nejm.org/cgi/content/full/346/22/1757 (accessed 06 May, 2009) Thompson, P. Key Challenges facing American nurse leaders. Journal of Nursing Management. November 2008. Volume 16 (8): 912-914 Wieck, K. Nurse Manager survival in an age of new health care priorities. Find Articles. May 2005. http://findarticles.com/p/articles/mi_qa4102/is_200505/ai_n13636411/pg_2/?tag=content;col1 (accessed 06 May 2009) Table of Contents Introduction……………………………………………………………………………… 1 Review of Related Literature……………………………………………………………. 1 Results from the U.S. Case……………………………………………………………… 5 Results from the Australia Case………………………………………………………… 8 Discussion………………………………………………………………………………. 10 Conclusion………………………………………………………………………………. 13 Reference………………………………………………………………………………… 15 Appendix A Letter to the Respondent Appendix B Questionnaire Read More