Supervisory Skills and Tools

Supervisors in the healthcare setting 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 in an efficient and economical manner. Every supervisor must take ownership of and accountability for his/her actions and decisions. It is vital that they recognize the importance of their roles in the organization and how their interactions with the staff have an effect on their employees’ performance.

Effective communication between supervisors and those from all departments can mean the difference between accomplishing goals and failure. Communication is used to disseminate information to others. Communication can be written, verbal, or non-verbal. Communication can be largely affected (93%) by body language and tone of voice, leaving only 7% of the intent based on actual words (AHRQ). It can also be affected by the style of delivery, such as how the speaker stands, sits, or engages the audience, such as by using direct eye contact. Ultimately, an effective communicator delivers a message so that the listener can hear the message.¹

Following up in a timely manner to ensure that what was said was clearly understood is a vital part of the communication process. Supervisors must keep communications open between nurse managers, department heads and administrators in order to be effective. Keeping the entire team advised on what is happening in the organization on a daily basis is essential.

Nurse leadership and Nurse management are two distinct concepts. Leaders focus on relationships rather than on tasks to accomplish a goal. As a leader, you must be committed to your passion and purpose and have the type of commitment that turns into perseverance. Many leaders are committed patient advocates, clinicians, or employee advocates, but the true test of commitment comes when it is difficult to get out of bed and go to work with a smile, yet you do because you know you are there to serve a purpose.²

The tasks and responsibilities of supervisors and leaders are different. Supervisors must oversee the work being done to ensure that it meets organizational standards and is completed on time.³ Supervisors have to complete technical and administrative tasks. The supervisory position exercises considerable judgment in applying professional knowledge in solving healthcare problems within established policies and practices.⁴ Leaders often act as intermediaries between supervisors and employees and for delegating tasks.³ Nurse leaders are an example to the entire team, and if the leader is unhappy, the team follows suit, and problems arise. Leaders must learn their own style of management, and convey this style to the team. Everyone can be a leader if they demonstrate leadership skills.³

Robert 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, Robert would assist the nursing supervisors and get other nurses to come into 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:

1. Works with Head Nurse to determine the optimum allocation of staff, per shift on each unit
2. The nurse leader is responsible for establishing the communication culture in the department. This may be fostered by being visible, having an open-door policy for accessibility, and creating a structure for communicating.¹
3. Planning and organizing activities for maximum efficiency. By doing so, Robert acts a catalyst for others by demonstrating a task orientation and giving workers a feeling of purpose, value and meaningful challenges.
4. Producing desired results through others and being accountable for the behaviors, actions and performance results of his employees, while maintaining the established high expectations and standards of the organization.
5. Realizing the importance of making informed decisions, taking decisive action in resolving problems, and confronting individual or healthcare team performance issues in an honest, timely, and constructive way.
6. Coaching, mentoring, training, and recognizing staff for their accomplishments so that they feel important.
7. Working effectively with other supervisors and peers who are members of the management team and setting a constructive, positive example for their employees and the organization as a whole.
8. Maintaining supervisory competencies to improve job performance effectively.

Transactional leadership: This form of leadership uses the reward or punishment system, and is good to use in critical situations as it ensures that projects are completed with a high level of accuracy.⁵

Transformational leadership: This form of leadership is “lead by example.” This type shows followers that the leader truly cares about them and the patients putting the organization's needs before the leaders.⁵

Democratic leadership: The leader gives everyone a voice in the decision-making process.⁵ Giving everyone a voice empowers the team to strive for excellence because they have a responsibility to carry out any decisions made by the team. The democratic leader has a close, one-on-one relationship with employees. 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 leader who is democratically inclined would engage her staff in decision-making and allow them to carry out their work in an independent manner. The group helps do the planning and problem-solving. Both make decisions, 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.

Authoritarian leadership: The leader has complete control, giving the team orders to be followed. Staff members are often made an example of if they make a mistake and are punished in front of their peers. Issues are always assumed to be the fault of the individual staff member and never the system or process.⁵

Laissez-faire leadership: This approach can be used when the team is experienced and needs no leadership, or the leader tends to be passive. Independent thinking is promoted but it can stall the decision-making process and may result in a few changes made in the workplace.⁵

When Linda deals with less experienced staff, 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 staff member working under her supervision. Younger and less experienced staff members might benefit from close observation, attentive guidance, and productive feedback. Linda’s role as a 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 healthcare professional standards; and maintain compliance with regulatory agency requirements. She also has to maintain a safe environment for her patients, staff, visitors, and clients. Linda changes her leadership style according to the situation, the needs of the medical center, and the way her staff responds 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.

To be effective in the organization, supervisors need to be aware of these three principles.

1. It is all about you, the supervisor. The effective supervisor is committed to his/her personal and professional development, enabling the supervisor to lead and assist others. Supervisors need to have integrity and deliver on commitments, they must be technically competent, they must understand the required tasks needed to accomplish a goal, and they must always be aware that they are a role model.
2. It is all about them, the employee. The second principle the supervisor should remember is that it is all about those we lead. Employees have to be motivated to action by an energized supervisor. The supervisor can accomplish this by creating an environment that motivates the employee to go beyond the basics of what is expected. The supervisor should focus on helping people perform more effectively and efficiently, as well as helping them become more productive and advance in their careers. It also shows them that as a supervisor you respect and value them as people and as professionals.
3. It is all about the organization. Supervisors are a part of the organization, but they are not the organization and as such must work with others to accomplish the organization’s short term and long term mission, vision, values, and goals. The effective supervisor is aware that he or she is an active member of the team and always works to better the team. Effective leaders have a forward-looking orientation and work to build the culture of their organization. The insecure leader wants their successor to fail. Any leader who fails to support an employee, for any reason, hurts the organization, therefore violating Principle Number Three. The essential three elements of this third principle are:

• Leader's intent- Where are we going and why?
• Culture and Values - What makes this place function effectively?
• Practice - Do we work to improve what we do?

The first step to a supervisor’s leadership effectiveness is to make a 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.

Power is the ability to influence others to believe, or to value as those in power desire them to or to strengthen, validate or confirm present beliefs, behavior or values.⁶ If the leader is personally motivated, it will influence the team to follow suit.

Robert is an achievement leader and motivates his staff by being self-energized and by inspiring his team. He actively develops productive working relationships with his supervisor, department heads and his peers. As a supervisor, Robert 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, Robert holds himself accountable for the performance of the entire team.’

Different styles of power include Expert, Reward, Legitimate, Referent, Coercive, Information, Tradition and Charismatic power.

Expert power is based on what one knows, what experience one has, and the special skills or talents one has.⁶ These leaders demonstrate their talents by leading by example or by demonstration.

Reward power is based on the right of some to offer tangible, social, emotional or spiritual reward to others for doing what is wanted and expected.⁶ There are some pitfalls with reward power. The team may not want to do what is expected without a reward.

Legitimate power is when one is being elected, selected or appointed to a position of authority.⁶ Examples of this power include Head nurses, Directors, and Supervisors.

Referent power stems from the affiliations we make and/or the groups/organizations we belong to or are attached to us.⁶ One of the pitfalls may be “riding on someone’s coattails.” If the leader is doing well, the team does well. But, if the leader makes a mistake, everyone feels guilty.

Coercive power exists when the use of or the threat of force is made to extract compliance from another.⁶ Coercion can make the team fear or distrust the leader, and the team will start to fall apart.

Information power comes as result of possessing knowledge that others need and want.⁶ The leader must know how to disseminate his/her knowledge to the team along with expectations. The knowledge must pertain to the job at hand.

Tradition power is that force exerted on us to conform to traditional ways. Traditions, for the most part, are social constructs, they invite or compel us to conform and act in predictable, patterned ways. The biggest pitfall with this type of leadership is “we’ve always done it this way.” We still must be open to new ideas that would make for a smoother transition.

Charismatic power is that aura possessed by only a few individuals.⁶ The leader has exceptional abilities to lead the team with confidence.

Robert 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.

Once a leader masters his/her style of leadership, the next step would be learning to create a team. Without the skills needed to build a team, the leader limits the success of the team. The five steps to creating a team are:

1. Establish Leadership: Leading includes fostering a trust relationship with the team, without trust, the team will not function smoothly. The leader must be honest and transparent.⁷
2. Establish relationships with each employee: Try to learn more about each member of the team, their skill steps, how they are motivated and their likes and dislikes.⁷ This gives the leader insight into the talents of each member. Remember to use shared governance as this gives the staff a feeling of importance, and will help keep the team cohesive.
3. Build relationships between employees: As the team develops a good working relationship with others on the team, study the way they work together. If a conflict occurs, try to resolve it amicably.⁷ Having the team come together to help work out issues is the only way to keep the team cohesive.
4. Foster teamwork: Encourage the team to share information, both amongst themselves and within the organization. It is essential that the leader offers assistance when needed, and being open to suggestions and concerns.⁷
5. Set ground rules for the team: Create the team’s vision and goals, and include the team in this process. The rules may be simple directives, but make sure the team has a voice in making the rules.

Team building is one of the most important responsibilities a manager has. It is an on-going process. As this process unfolds, your team members will begin to trust and support one another and share their skill sets with one another.⁷

Nurse supervisors have the responsibility to supervise all employees by applying professional knowledge. There are many dimensions to a supervisory position, and the supervisor must stay up-to-date on all policies and procedures. The competencies leaders should possess include:

1. Communication- Express ideas clearly and decisively, encourage direct and open discussions about important issues and convey ideas through examples and images.⁸
2. Conflict-Resolve conflict before it grows and spreads through the team. A leader must act with fairness and actively listen to the team.
3. Diversity- Leader will work effectively with people who differ in race, gender, culture, age or background.⁸ The leader must be able to treat everyone fairly and with respect.
4. Employee development- Offer constructive feedback and encouragement; delegates work and encourages individual initiative.⁸
5. Relationships- As already examined earlier, relationships are of the utmost importance to a well-running team. The supervisor has an obligation to gain the trust and respect from the team to better serve the patients and families.

Once the leader ensures that the team is working well together, the next step for the leader is staffing, keeping in mind the different skills set that each member possesses. Safe staffing ratios differ in each facility. Having enough skilled nurses on a unit is the key to patient safety, and might also reduce nurse burnout

Linda’s, who is the head nurse in ICU, 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. 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 patient acuity – of 1 nurse to 2 patients.

To meet the demands placed on two acute care units,  Linda flexed the times her staff came into work. She also worked with the other Nurse Managers to assist them with call-offs. Linda encouraged all the Nurse Managers to receive a 24-hour report from the off-tour Nursing Supervisor and to discuss their staffing plans.

When Linda’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, a Nurse Executive had to answer the following questions before these changes could be implemented:

• Does the unit operate 24 hours a day, 7 days a week, or does it operate only within specific hours?
• What is benefit time usage and is adequate coverage provided so that annual leave and pre-planned sick leave is used appropriately while the unit is safely covered?
• Are shifts 8 hours, 12 hours, or shortened to 4 hours during peak hours of operation (e.g., heavy medication passes, skin care rounds)?
• What are the current policies related to overtime use, especially on the weekend?

Nurse Managers have 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 into this category. The nurse manager must also be prepared for the unexpected, such as disaster planning, accidents that can potentially involve a large number of people, and other non-routine events.⁹

Some hospitals have their own staffing pool or work with traveling nurse organizations, and these personnel fall into 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 has been hired into a staffing pool to work when needed. This could cost less money than keeping someone on overtime.⁹

Many nursing units use block staffing. Block staffing entails scheduling a fixed staff mix for each shift. Staffing for general medical-surgical units may have the greatest number of nurses on the day shift when all bathing and hygiene care is provided and preparation of patients for scheduled procedures occurs, such as going to the OR. On these units, the number of nurses may be greatest on the day shift, followed by the afternoon shift when patients are still awake and involved in getting in and out of bed or having scheduled procedures such as surgical dressing changes. Night nurses typically are involved in assessment, medication delivery, administration of intravenous fluids and medications, and answering call lights. Therefore, complement of staff is lowest on this shift, especially in general medical-surgical units. ¹⁰

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 patients on each unit is determined.

The Prototype Classification System is considered subjective and descriptive.¹¹This system classifies patients with the same diagnosis into the same group to predict patient needs. Prototype staffing 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’ demands for care differ despite the same medical diagnosis.

There are two ways to prepare a staffing schedule: centralized and decentralized staffing.

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.¹² 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:

1. Being a part of what is going on. Notified in a timely manner of the organization’s plans, policies, and future events, how he/she can be involved, and how changes may affect him/her.
2. Specialized awards for being “Employee of the Month” and/or Employee of the Year which may be given out during “Nurses’ Week.”
3. Meaningful Work: Employee can readily discern the contribution his/her work makes towards the achievement of organizational goals.
4. Frequent feedback on performance: This can be done verbally and in print. Emphasize the positive.
5. Recognition for good work by boss, supervisor, and coworkers, e.g., receiving an award pin in front of the healthcare team. Having good deeds written about in hospital newspaper,
6. Fairness from the leader by recognizing all those who have given their valuable work and time to help achieve the organization’s goals.
7. Tangible accomplishment: When a worker has a sense of closure on specific projects by helping to set daily, weekly, or monthly goals when routine tasks seem endless. Encouraging employee to seek new and better ways of doing work and recognizing this accomplishment.
8. Giving the right amount of supervision. Too little or too much supervision can make an employee feel inadequate or not important. Too much supervision can frustrate the employee to the point she/he feels that the responsibility for the task is the supervisor’s and there is no feeling of ownership.
9. Consistent rewards for exceptional work. These could be financial bonuses, positive comments in writing to help in yearly performance evaluations, increased salary, supervisor recognition, etc.
10. Flexible work schedule. An employee has other responsibilities, such as childcare, being involved with child’s school activities, caring for others at home, and must continually prioritize these needs. Often, out of necessity, this employee calls in. Flexible work schedules and job sharing might help to motivate this employee and help to improve attitudes and reliability.
11. Commitment and personal involvement. Allow employees who want to be involved with decision making to do so. Achievement-minded supervisors need to recognize those employees who are only comfortable with following established processes from those who are willing and able to explore new challenges.
12. Helping those who are career oriented. Coaching and mentoring employees who are interested in career advancement. Making job assignments which would provide opportunities for employees to grow, network, and advance their careers. Encouraging furthering education and being flexible with work schedule.
13. Developing Confidence. A supervisor realizes when an employee is struggling and is not qualified to accomplish an assigned task. This makes an employee feel frustrated and incompetent. Before the problem escalates, a wise supervisor should consider additional training for the employee or a reassignment of tasks to be done. The employee should be listened to and involved in this decision.
14. Leader’s behavior. A leader’s behavior and attitude is a vital incentive for achievement motivation. This is reflected by showing personal appreciation and approval, or can be reflected by neglect, apathy, or disapproval. A wise leader who knows his/her weaknesses has those around him whose personal style is complementary instead of similar.

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. 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 leader’s authority, building a trusting, honest relationship with the leader, and achieving goals without being totally dependent on the leader.

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