The purpose of this course is to provide supervisors with skills and tools which will assist them in meeting the challenges of being one of the primary motivators of change within organizations designed to provide safe and efficient healthcare.
This course is designed so that the healthcare professional supervisor will be able to:
Supervisors in the healthcare arena can be nurse managers, department heads, and/or administrators. Successful supervisors are dependent on their ability to understand the organization's mission, vision, and values and their ability to utilize staff to get the job done efficiently and economically. Each supervisor must take ownership of and accountability for his/her actions and decisions. It is vital they recognize the importance of their roles in the organization and how they affect every employee they interact with on a daily basis.
Effective communication between supervisors and those from all departments can mean the difference between accomplishing goals and failure. This means that communication between employees, managers, peers, co-workers, and the internal and external resources who work with or for different departments must be clearly defined and understood by all involved in the process.
Following up in a timely manner to ensure that what was said was clearly understood is vital. Supervisors need two-way communications with their own supervisors in order to be effective and need to keep them advised on what is happening at their level of the organization.
Nursing leadership and nursing management are two distinct concepts. Leaders focus on relationships rather than on tasks to accomplish a goal. Leadership is commonly defined as one person's ability to influence others. A leader is a guide who uses his/her personal traits and the collective efforts of all those involved to guide staff, clients, and families through a process designed to achieve the organizational goals.
Supervisors are protectors of existing order. They have a strong sense of belonging to their organization and do not see themselves as separate from the organization. The achievement of organizational goals is their prime concern. To accomplish goals within the organization, they must work with other people while following established policies and procedures. They are concerned with process and are guided by the established organizational goals, policies, and practices. Supervisors focus on tasks to accomplish a goal. Final decisions are the result of following these policies and procedures. Due to the instinct for survival, they will tolerate mundane tasks and practical work.
Leaders question established organizational processes and inspire others to look for options which can bring better results. They are concerned with achieving personal goals and are found at any level in the organization. They have a personal mastery which impels them to create change. Mundane tasks are not tolerated well and as leaders, they seek out risks when the rewards are high. Leaders relate to people in an empathetic and intuitive way. As leaders, they are not satisfied with the status quo of established organizational goals and policies. They seek change and like to try innovative new systems and concepts.
Ramadan is an experienced Registered Nurse who has worked in all areas of the hospital for the last fifteen years. As a staff nurse when staffing was critical, Ramadan would assist the nursing supervisors and get other nurses to come in to work with him. He was an ideal choice for a Nursing Supervisor and believes in team work.
Presently, he is a Nursing Supervisor of a 450-bed hospital and works on the night shift. He believes in leading by example and in listening before responding to situational challenges. He is well respected and is appreciated for building progressive healthcare teams. He has established productive supervisory practices such as:
Supervisor or managerial leadership power is not a new concept and as David C. McClelland and David H. Burnham (1976) stated in their article Power is the Great Motivator: “Good managers are not motivated by a need for personal aggrandizement, or by a need to get along with subordinates, but rather by a need to influence others behavior for the good of the whole organization. Managerial leadership power is the state of being personally motivated to influence others to achieve a goal.”
Ramadan is an achievement leader and motivates the night staff by being self-energized and by inspiring his healthcare team. He actively develops productive working relationships with his supervisor, nurse managers, department heads, and his peers. As a supervisor, Ramadan is always asking himself, what can I contribute to the achievement of the organization's goals, how can I stay focused and achieve positive results? In essence, Ramadan holds himself accountable for the performance of the whole.
Ramadan was asked to develop a plan to that would prevent injuries related to falls. As a powerful achievement leader, he made the most effective use of his time and developed a working team to brainstorm ideas. He focused on the contributions his individual staff members could make to the effectiveness of achieving this goal. He encouraged team members to contribute their expertise and communicate laterally on the plan. As a team, they created a mattress which would be placed next to a patient who has a history of falls. This working team also encouraged the use of audible bed alarms and making every 30-minute rounds on fall-risk patients. They established a checklist for the healthcare providers and set up a system to collect data related to falls. When a patient fell, they had a team huddle to discuss how to prevent future falls on all shifts. Verbal and written praise was given to the participants of his work team. Their supervisors were informed of his team's performance and their contributions to the overall goals of the organization. Credit was given where credit was due.
Kate Christmas (2009) in her article, The Year of Positive Leadership stated, “in the nursing profession, as in many disciplines, leaders have evolved from an old school approach of control and command to a much more participatory style which includes individualized mentoring. True leadership requires equal parts vision and humility, with the ability to confront hard truths and to coach and mentor.”
There are many different leadership styles and one chooses the style according to the results that need to be obtained and the particular needs of the user. Basically, there are three fundamental leadership styles, Democratic, Autocratic, and Laissez-Faire. Regardless of leadership style, the final responsibility for the achievement of the goals of the department or organization rests solely on the supervisor/manager/leader.
The Democratic leader uses the team or participatory approach, and the feeling of responsibility is shared among the leader and all team members. This leader has a close, one-on-one relationship with employees. This responsibility for achievement is felt by all and success is more likely to occur. Democratic leadership draws its strength from the team members who are valued for their views and opinions. By allowing team members to contribute innovative ideas, this leader hopes for mutual consensus in order to achieve the given targets. A nurse leader who is democratically inclined would engage her nurses in decision-making and allow them to carry out their work in an independent manner. The group helps do the planning and problem solving. Decisions are made by both, but the final responsibility lies with the leader. Communication is directed down, up, and laterally. The responsibility for achievement is felt by all involved, and the leader has confidence in the group and delegates authority. This leader’s rapport with subordinates is high and when dealing with change they adapt well. This approach is particularly useful when the course of action is unclear. Crisis management with the team approach is not as good as the autocratic leader.
An Autocratic leader provides instructions without looking for inputs and superintends his/her nurses closely, exercising tight control. Autocratic leaders use centralized decision making that is independent of the opinions of subordinates (Nagelkerk, 2006). This leader does the planning and problem solving, directs communication down, does not delegate, feels the responsibility for achievement, has little confidence in subordinates, lacks rapport with subordinates, does not feel comfortable giving out authority, and tends to micro-manage. Usually, this leader thinks he/she has low performing groups that require closer supervision. This leader strives to be consistent and fair. Autocratic leaders are good at crisis management but are not effective change agents.
A Laissez-Faire leader tends to be passive. This leader is comfortable deferring daily decision-making to his/her subordinates and usually does not set policy. Due to this attitude, teams that are supervised by a laissez-faire leader tend to be less productive, and the members become easily frustrated and experience low levels of job satisfaction. If there are established goals and self-directed individuals are on the team, this group can be successful. Compared to the Autocratic or Democratic leader, these teams are generally less productive.
An experienced nurse leader would select a leadership and management style that would work best in any circumstance. Brenda, a nurse manager of the ICU, uses a democratic role with her experienced nurses when she needs to upgrade her monitoring equipment. She allows the nurses to use it, test it, and evaluate it, and has them help compare the costs of different equipment which safely meets the needs of the patients.
When Brenda deals with less experienced nurses she is autocratic and she gives more direction. She gives them one-sided instructions and closely monitors their work. She changes her leadership style according to the age and expertise of the nurses working under her supervision. Younger and less experienced nurses might benefit from close observation, attentive guidance, and productive feedback. Brenda's role as a Nurse Manager is complex and entails managing human, operational, and capital fiscal resources. She must also develop and promote staff development and educational opportunities; make sure the staff is practicing using the appropriate professional nursing standards; and maintain compliance with regulatory agency requirements. She also has to maintain a safe environment for her patients, staff, visitors, and clients. Nurse Managers balance complex healthcare environments and job demands as well as maintain productivity and delivery of quality care to consumers in hospitals and community healthcare settings (Yoder-Wise, 2007). Brenda changes her leadership style according to the situation, the needs of the medical center, and the way her nurses respond to her instructions.
Today, to meet the needs of constant change, nursing has moved towards a shared model of management which involves all nurses in decision-making. In this democratic style of leadership, nurse leaders encourage the staff to become actively involved in decision-making activities. Implementing the organization's mission, vision, and values providing quality care in all departments is vital. Successful supervisors develop competencies as noted on this chart.
The essential three elements of this third principle are:
The first step to a supervisor’s leadership effectiveness is to make the choice to be a leader. Then, focus on your employees and help them succeed. If the supervisor can accomplish those two goals, the organization can successfully advance.
Creating an Organizational Team
Organizational leadership requires the coordinated efforts of a team of managers to lead their employees to accomplish established tasks and goals. The leadership team - which can include Nurse Managers and Supervisors from all departments - usually convenes on a regular basis to formulate policy, solve problems, and make decisions.
Tenna is a Chief of Operations and has the organization's mission, vision, and values to guide her in setting the foundation for present and future endeavors. To determine who should be on her leadership team, she evaluates which individuals would be most effective in accomplishing the goals of the organization. These individuals will be directly responsible to her.
Questions she uses to guide her before she chooses her leadership team:
Tenna’s most recent challenge was making sure all Nurse Managers and Nursing Supervisors were staffing for productivity. She encouraged her Nurse Managers and Supervisors to use a mixed, skilled workforce to supplement registered nurses, licensed practical nurses, and nursing assistants so that there would be more direct, hands-on nursing care. Patient classification systems (PCS) were used to provide data so charge nurses and team leaders can make informed, workable assignment decisions.
The Nurse Managers were on duty 24 hours a day and had to staff their units seven days a week. Staff mix can vary by unit and by days and times during the week (Sullivan & Decker, 2005). Staffing involves hiring, orienting/precepting, and deploying qualified nurses to meet the demands for client care. The individual unit has specific guidelines indicating the required staffing/patient ratio. As an example, the intensive care unit requires an all registered nurse staff with a maximum nurse to patient ratio depending on the patient acuity of 1 nurse to 2 patients.
The acute care units and the emergency room Nurse Managers have to be creative and work out a staffing mix which would meet the needs of the patient and the capabilities of the staff in order to ensure that all patients receive quality care in a timely manner. For example, Nursing Supervisors who were in charge after 4 PM had to constantly communicate with the emergency room nurses, the medical administrator doing bed placement, the acute care nurses, and environmental services to ensure that an acute care unit bed was clean and available. After all concerned met and discussed the issue, it was decided that once an order to admit was written and the Nursing Supervisor was notified of this, the patient had to be placed in his/her assigned bed within 30 minutes.
To meet the demands placed on two acute care units, the Nurse Manager Karyne flexed the times her staff came in to work. She also worked with the other Nurse Managers to assist them when there were call offs. Tenna encouraged all the Nurse Managers to receive a 24-hour report from the off tour Nursing Supervisor and to discuss their staffing plans.
When Tenna’s Nurse Managers developed a unit staffing plan, they evaluated the admission trends and case mix from previous years. They also took into account the previous year's allocated personnel budgets. If staffing changes were perceived to be needed due to increased patient acuity levels and changes in the workforce, Tenna as a Nurse Executive, had to answer the following questions before these changes could be implemented:
Nurse Managers had to know which of their employees were in fixed positions and who was in a variable position. An employee who was a full-time equivalent (FTE) is often salaried and their pay is not dependent on unit workload or client acuity. These individuals remain constant to facilitate unit operations. Nurse Managers, unit secretaries, and educators fall within this category.
Variable FTE positions are held by employees who are scheduled to work based on unit census and acuity (Yoder-Wise, 2007). Some hospitals have their own staffing pool or work with traveling nurse organizations and these personnel fall within this category. Some hospitals have instituted policies and procedures to closely monitor patients to prevent them from falling or from hurting themselves or others. These patients are placed on close observation or one to one observation. This may require using staff that have been hired into a staffing pool to work when needed. This could cost less money than keeping someone on overtime.
Most of Tenna’s nursing units use block staffing. Block staffing entails scheduling a fixed staff mix for each shift (Sullivan & Decker, 2005). Joyce, one of the Nurse Managers, is in charge of a 50-bed nursing home. During the day, staffing is the highest as many of the patients require extensive care. Patients must be fed, bathed, dressed, and many of them require daily procedures, scheduled procedures that may take place at another facility. On the evening shift, patient care needs are also very high. On the night shift, there is less staff. Night nurses typically are involved with answering patient call lights, assessment, medication delivery, administration of intravenous medications, checking 24-hour orders, and calling the Medical Officer in the emergency room when a patient becomes unstable.
Joyce schedules staff to come to work at 6AM because the night staff needs assistance to get patients out of bed so they can eat or be fed in the dining room. She also has a medication nurse come in from 6 AM until 2:30 PM; if they are working 12 hours, they may be scheduled until 6:30 PM. Her staff is appreciative of her democratic leadership style because she listens first, asks for their suggestions, and then makes a decision.
If Joyce can provide care to a greater number of patients with her existing staffing pool of budgeted nurses, her unit productivity increases. In evaluating the quality of care outcomes and staffing decisions, she evaluates the patient acuity, depth of service, and case type. When planning staffing patterns, she keeps in mind the skill level, clinical judgment, and critical thinking ability of her staff. Her charge nurses need all of these requirements to safely manage this 50-bed unit.
Patient Classification Systems predict nursing care requirements at the individual patient level in order to determine staffing requirements, project budgets, define an objective measure for costing out nursing services and to maintain quality standards (Moiden, 2003). PCSs are used in many hospitals as a valid and reliable means to justify nurse staffing and to measure unit productivity. Therefore, PCSs are not about nurses; they are about patients. The individual patient acuity level determines the unit to which the patient is assigned, the care delivery system that is needed, the assignment of personnel, and the cost of nursing service.
To calculate the time needed to complete a patient's care, time and motion studies are done. Each shift Joyce has her charge nurses complete the PCSs to determine the number of nurses required for safe patient care. There are two major types of PCSs: factor system and prototype.
The Factor Classification System is the most objective and reliable system because it allows the PCS tool to be quantified. Time and motion studies are done to assign a time or rating for individual procedures. Acuity numbers for individual patients are summed up and the number of nurses needed to care for the patient’s on each unit is determined.
The Prototype Classification System is considered subjective and descriptive (Decker & Sullivan, 2005; Yoder-Wise, 2007). This system classifies patients with the same diagnosis into the same group to predict patient needs. This does not account for specific patient differences which would increase in acuity level (e.g., a person who had his gall bladder removed and then becomes septic and needs admission to Intensive Care is not the same as a patient whose recovery is within normal limits.) These patients demand care differ despite the same medical diagnosis.
There are two ways to prepare a staffing schedule: centralized and decentralized staffing.
This is usually done for all units or groups of units by a staffing coordinator. This coordinator usually uses a computer software program or an automated system. Staffing plans for each unit in the hospital are inputted to ensure that minimum staffing requirements are listed. The staffing coordinator is responsible for inputting scheduled variances, benefit time, running daily staffing records, and finalizing schedules.
Automated systems which are used by the staffing coordinator or nurse manager allow nurses to have input into their work schedules. This increases job satisfaction and leads to greater nurse retention.
Decentralized scheduling is done at the unit level. Joyce uses decentralized scheduling and is responsible for completing and posting the final staffing schedule. Using this type of scheduling, she is unaware of what the staffing is for the rest of the hospital and consequently in the morning meeting with the Nursing Supervisor and other Nurse Managers shares and asks for staff as needed.
She has allowed shared governance and self-scheduling to be used but only if the unit is covered on all shifts. Staff nurses work collaboratively to plan the work schedule and are closely involved in work-related issues; this enhances job satisfaction on her unit. When the staff has made a schedule, it is submitted to Joyce. Based on the patients and staffs needs, she approves the schedule or makes changes to it.
Motivating and upgrading employee achievement is a continuous process. According to Maslow's hierarchy of needs, it is the higher needs (ego and self-actualization needs) that motivate and continue to motivate as long as they are being satisfied. The expected needs, which do not serve as incentives, are salary, fringe benefits, healthy work environment, job tenure, pension plans, break times, etc. What does influence achievement is the satisfaction of higher needs, represented by enjoyable work, recognition for job performance, responsibility, advancement with pay incentives, educational opportunities, and the way employees are allowed to participate in the success of the organization.
The kind of motivation a leader wants his/her employees to have is achievement motivation. The following is a list of some incentives:
Nursing Managers hold formal supervisory roles in healthcare organizations and as such develop followership. Followership is an active (versus passive), interpersonal process of participating by following a leader or manager (Nagelkerk, 2006; Yoder-Wise, 2007). Effective followership demonstrates attributes such as communicating on a regular basis with the supervisor, cooperating, collaborating, being an effective team member, influencing others, promoting teamwork, accomplishing assigned tasks with a positive attitude, recognizing the leaders authority, building a trusting, honest relationship with the leader, and achieving goals without being totally dependent on the leader.
Time and focused energy are needed to motivate the staff and to ensure they are committed to accomplishing organizational goals. The success of any business is in valuing and developing its people. Only by being receptive and responsible for patients and for employees working in all departments can supervisors meet the challenges that constant change gives them on a daily basis. Each supervisor has a leadership style which can be used positively or negatively and it is up to each leader to develop a style which is constructive and not destructive.
Leaders have to contend with the dualities of leadership: knowing when to follow and when to not follow, the responsibility to question and the responsibility to execute, and dedication to mission first and dedication to your employees above all. These dualities highlight the point that disciplined action does not mean rote action. Disciplined action means that you begin with a framework of core values (be), you meld those values with knowledge and insight (know), and finally, you make situation-specific decisions to act (do). Leadership begins not with what you do, but who you are (Crandall, 2006).
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This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)
Administration & Leadership, CPD: Promote Professionalism and Trust