Identifying a Problem and Managing Change in Nursing through the use of Lewin's Change Theory

Problem

A problem that has been identified as needing changed is low attendance at unit staff meetings.  Low staff attendance at unit meetings hinders communication of unit changes and recommendation.  Inadequate communication between staff and management negatively affects the ability to achieve the goals of the organization and promote optimum patient outcomes.

Advantages/Disadvantages of Change

There are many advantages to staff attendance of meetings.  Rapport is developed and improved between staff and management when communication is promoted.  Staff would have an increased awareness of changes taking place in the department by attending meetings.  Staff must be aware of changes taking place in order to remain compliant. 

The disadvantages of increased attendance at staff meetings are related to staff perception and attitudes towards attendance.  If the staff views meetings as an inconvenience or waste of time, they perceive they are being “forced” to attend.  If staff has a negative connotation regarding meeting attendance, they will not be receptive to the information offered.  In order to avoid the disadvantages of increased attendance, the staff must view the meetings as important and informative.  Staff must view the meetings as having a positive influence on their nursing practice.       

Change Theory

Lewin’s Change Process will be used to address and change to problem of low attendance at unit staff meetings.  Lewin suggested three elements for successful change and promoted increased understanding about how groups and organizations change (Huber, 2010, p.59).  This method was chosen due to the emphasis placed on the idea that no single intervention is suited to all situations (McGarry, Cashin, and Fowler, 2012).  The plans for change and methods to achieve change are individualized and based upon the group dynamics of the staff undergoing change.  Behaviors related to and barriers to overcome to achieve change are explored and understood in order to develop an individualized change plan. 

Outline a Plan for Change

The outlined plan is based on the three step model of change developed by Lewin: unfreezing, moving, and refreezing.  The change process begins with unfreezing.  Unfreezing would take place by motivating staff and assessing readiness for change.  The staff would explore the problem of meeting attendance and work to generate solutions.  Those involved in the change must understand and accept the necessity of change (Huber, 2010, p.60).  Management would provide current meeting attendance percentages and offer education to staff related to benefits of increased meeting attendance.

In order for the staff to feel motivating to make change, conditions must be created to promote new behaviors.  Management would promote change by supporting staff and allowing for input to identify barriers to the ability to attend meetings.  The behavior of low attendance at meetings can only be unlearnt if the staff is willing to challenge the existing problem.  Fears and opinions related to mandating an increased attendance rate would be explored.  Resistance to change is overcome by understanding and counteracting barriers and anxiety related to the change (McGarry et al., 2012, p.66). 

Moving is the next step of the change process.  Moving occurs when the staff moves to a new level of behavior.  The process of moving requires trial and error.  In order for the change to occur on the individual and group level, the expectation of meeting attendance must be specific and accepted by the staff (McGarry et al., 2012, p.66).  Management and staff would agree upon a required number of meetings that must be attended annually.  Management would also encourage staff input related to barriers of meeting attendance.  In the refreezing phase, management would make changes to overcome meeting attendance barriers.  Visible increases in meeting attendance would occur as a result of the change being planned and initiated (Huber, 2010, p.60).     

Refreezing is the final step of Lewin’s model of change.  The new changes are integrated and stabilized during refreezing.  Equilibrium of the environment and behaviors is re-established during this stage.  Adjustment to change must be achieved at the group level for the change to be sustained (McGarry et al., 2012, p.267).  The manager plays a vital role in the refreezing stage.  Reinforcement of behaviors is crucial.  Leaders must provide positive feedback, encouragement, and constructive criticism (Huber, 2010, p.60).  Monitoring attendance and discussing positive outcomes related to increased attendance with staff encourages open communication between management and staff related to change behaviors.      

Anticipate Reactions

Staff support and feedback from nursing leadership is necessary for the long term success of increased staff attendance at meetings.  Staff may react negatively to the change of mandating increased meeting attendance.  By including frontline staff in the change process, management would increase staff buy-in.  If staff remains unhappy and views meeting attendance as an inconvenience, management would encourage open communication and suggestions for overcoming barriers.  Allowing staff input on meeting day/times/length of meetings would encourage effective change implementation. 

Lewin’s model of change is a fluid process.  Change results from trial and error.  It requires staff support.  The manager’s role in change is to offer constant education, motivation, enthusiasm, and team building (Huber, 2010, p.60).  In order for change to be effective and sustained, the staff must view the change as congruent with their values. 

References

Huber D L 2010 Leadership and nursing care managementHuber, D. L. (2010). Leadership and nursing care management (4th ed.). Maryland Heights, MO: Saunders Elsevier.  201311171146071826182008

McGarry D Cashin A Fowler C 2012 Child and adolescent psychiatric nursing and the 'plastic man': Reflections on the implementation of change drawing insights from Lewin's theory of planned change.McGarry, D., Cashin, A., & Fowler, C. (2012). Child and adolescent psychiatric nursing and the 'plastic man': Reflections on the implementation of change drawing insights from Lewin's theory of planned change. Contemporary Nurse: A Journal for the Australian Nursing Profession, 41(2), 263-270.  2013111711450872676897

Staff Retention and the Role of the Nurse Manager

I have experienced high turnover rates secondary to low staff morale in the acute care setting.  Staff burnout was apparent and influenced by many factors: heavy workload, low autonomy, relationship between leadership and frontline staff, and perceived lack of recognition.  Nursing staff verbalized feelings that they were not appreciated by nurse management and were led to believe “everyone can be replaced.”  During a time in which much change is taking place in health care, staff felt unheard and powerless.  The turnover rate of the unit received much scrutiny and investigation by the human resources department.         

Aging population, increasing nurse retirement, and the growth of complexity of healthcare demands have affected nurse retention.  Low staff retention affects the budget of nursing units and the healthcare organization.  According to O'Brien-Pallas, Murphey, Shamian, Li, and Hayes (2010), the cost of replacing a medical surgical nurse is $42,000 and the cost of replacing a specialty nurse is $64,000 (p.1074). 

Staff turnover negatively impacts staff morale and group productivity.  Decreased retention and increased turnover rate negatively impact healthcare organizations and the quality of care delivered.  New employees have a lower productivity than tenured staff.  An increased turnover rate threatens the quality of patient care delivered (O’Brien-Pallas et al., 2010).  Improving job satisfaction and retention rates is a concern and responsibility of nursing management.       

Nurse retention is influenced by leadership style and job satisfaction.  The leadership style of the nurse manager affects employee satisfaction.  Job satisfaction is influenced by many factors: autonomy, hours worked, workload, ability to provide quality care, relationship with colleagues, and advancement opportunities.  The ability of management to understand what makes nurses feel satisfied affects their ability to facilitate satisfaction (Abualrub and Alghamdi, 2012). 

Retention of the nursing workforce is a top priority for nurse managers.  Therefore, job satisfaction is a responsibility of nurse managers.  According to Parker and Hyrkas (2011), a nurse manager must effectively manage nurses while understanding the importance of staff satisfaction and the effect on retention (p.568).

The roles and responsibilities of nurse managers are focused on the needs of human beings.  Nurse satisfaction and patient outcomes must maintain priority in the practice of management.  During times of rapid change in healthcare, managers must promote the growth and development of staff as needs and opportunities change.  A nurse manager is responsible for the seamless management of the goals of the organization and the needs of staff.    

Abualrub R F Alghamdi M G 2012 impact of leadership styles on nurses' satisfaction and intention to stay among Saudi nurses.Abualrub, R. F., & Alghamdi, M. G. (2012). The impact of leadership styles on nurses' satisfaction and intention to stay among Saudi nurses. Journal of Nursing Management, 20, 668-678.  20131116110001262264967

O'Brien-Pallas L Murphey G T Shamian J Li X Hayes L J 2010 Impact and determinants of nurse turnover: A pan-Canadian study.O'Brien-Pallas, L., Murphey, G. T., Shamian, J., Li, X., & Hayes, L. J. (2010). Impact and determinants of nurse turnover: A pan-Canadian study. Journal of Nursing Management, 18, 1073-1086.  20131116110503260530829

Parker S Hyrkas K 2011 Priorities in nursing management.Parker, S., & Hyrkas, K. (2011). Priorities in nursing management. Journal of Nursing Management, 19, 567-571.  20131116105214561599970

Goal Setting for Nurse Managers and Healthcare Professionals

Goal setting improves employee performance by narrowing focus/attention and motivating employees.  According to Module 4 Lecture 8, goals provide direction, provoke persistence, energize, and cause people to seek task relevant knowledge (Montag, 2013).  Goal setting is a function of management and is completed during the planning process.

Goal setting is a function of healthcare professionals.  Whether a staff nurse is setting goals for a patient or a manager is setting goals for a unit, the outcome of a successful healthcare professional is measured by the achievement of goals.  According to Roussel (2013), an effective manager sets goals during the planning process and allows for input from all levels of an organization.  By involving all levels of the organization in the goal setting process, the manager ensures that goals are SMART goals and increases buy in from staff (p.482).

Specific (Are the goals set specific for the area of nursing for which they will be applied with distinct desired outcomes?)

Measurable (Are the goal outcomes measureable in the healthcare setting?)

Attainable (Is the staff/healthcare organization able to attain the goals set?)

Relevant (Are the goals relevant to the mission, vision, and value of the healthcare organization and unit?)

Time-Bound (Do the goals have a definite start and end point for the healthcare professionals?)

A nurse manager can use the nursing process to include staff at all levels in the goal setting process.  By using the nursing process and including staff, staff will feel a stronger commitment to the achievement of the set goals.  The nursing process can be used for goal setting as follows:

1.      ASSESSMENT:  the nurse manager and staff recognize the problem or opportunity for improvement.

2.      NURSING DIAGNOSIS:  analysis of pertinent data by management and staff leads to improved understanding of the problem and causes

3.      PLANNING:  the manager and staff can develop goals and strategies to attain them

4.      IMPLEMENTATION:  the manager and staff design a plan for execution

5.      EVALUATION:  the manager allows feedback from the staff on outcomes and realization of return on investment is recognized (Roussel, 2013, p.483).

      Effective goal setting by a nurse manager includes the frontline nursing staff.  By including all levels of staff, all levels of the organization feel a commitment to the achievement of the goals due to their involvement in goal setting.  Effective nurse managers/leaders recognize the important role staff plays in achieving attainable goals.  By setting SMART goals and including staff in the planning process, the healthcare organization increases the probability of successful goal achievement. 

Montag, T. (2013). Goal-Setting Theory. Module 4 Lecture 8. 

Roussel L 2013 Management and leadership for nurse administratorsRoussel, L. (Ed.). (2013). Management and leadership for nurse administrators (6th ed.). Burlington, MA: Jones & Bartlett Learning.  20130914130953335672974

Power and Influence in Healthcare

Two of the five bases of power discussed in Module 10 Lecture 5 Power are as legitimate and expert.  Legitimate power is power that results from a formal position.  Expert power is power that results from specialized information or expertise.  Physicians have a hierarchical form of power derived from legitimate and expert power.  Physicians have a formal position that, historically, has led to a certain level of respect.  Physicians also have a position based on knowledge and expertise from with they receive power.  The power and traditional view of physicians as infallible can lead to blind authority.

Cialdini (2009) stated that “the simultaneous blessing and curse of such blind obedience to authority is its mechanical character.  We don’t have to think, therefore we don’t.  Although such mindless obedience leads us to appropriate action most of the time, there will be conspicuous exceptions because we are reacting, not thinking” (p.181).  Blind obedience to authority can result in devastating outcomes for customers in the healthcare settings.  Physicians are human.  Physicians often have tremendous responsibilities to be fulfilled in a limited amount of time.  Blindly accepting the authority of physicians and their orders without checks and balances is not in the best interest of the healthcare organization or its customers.  

   

Cialdini (2009) outlined this concern in stating “the worrisome possibility arises, then, that when a physician makes a clear error, no one lower in the hierarchy will think to question it-precisely because, once a legitimate authority has given an order, subordinates stop thinking in the situation and start reacting” (p.181).  Many nurses, especially new nurses, fear questioning the order of a physician due to the inherent authority and power in place.  Blind obedience results in medication and care delivery errors.  Patients, nurses, pharmacists, etc should all be taught and encouraged to have a comfort level with respectfully questioning an order that appears to be in error.

Electronic health records and electronic order entry has allowed for another form of checks and balances within the healthcare hierarchy.  As a physician enters an order in the computer system, the program alerts the physician if the order entered is questionable or contradictory of best practice.  Medication dosages, routes, frequencies, etc are all checked by the computer system for consistency with current recommendations.  Technological advances provide another opportunity to prevent errors within the healthcare organization due to blind obedience.  Power and influence affect one another.  Many individuals in positions of power deserve the influence they have.  While authority and influence should be respected, all healthcare providers are human and subject to error.  Therefore, systems should be in place to prevent errors and discourage reacting without thinking.

References

Cialdini R B 2009 Influence: Science and practiceCialdini, R. B. (Ed.). (2009). Influence: Science and practice (5th ed.). Boston, MA: Pearson Education, Inc.  

Leadership Characteristics and Nursing Leadership Theories Recognized

The following are the core leadership competencies and characteristics with examples of how they could be displayed by nursing executives/leaders:

1.  Communication and relationship management (effective communication is witnessed between the leader and all roles and ancillary departments encountered)

2.  Leadership (this nurse leader is an effective leader of inpatient and outpatient unit staff, including nurses, physicians, and ancillary services)

3.  Business skills and principles (able to manage business skills and principles by maintaining working relationships and reporting to business and financial departments within organization)

4.  Knowledge of health care environment (the nurse director must maintain a vast and updated knowledge of issues and evidence based practice related to the specific departments)

5.  Professionalism (able to manage conflict resolution and other situations while maintaining professional and neutral behaviors) (Huber, 2010, p.1). 

Along with these core competencies, the nurse leader should also display characteristics described by Collins (2001).  An effective leader has dual characteristics of “modest and willful, humble and fearless” (p.22). 

Situational theories are a group of nursing leadership theories based on the foundation that organizational behaviors are contingent on the situation or environment.  To effectively lead, leaders must have the diagnostic ability to assess and vary leadership skills depending on the situation at hand (Huber, 2010, p.14).  In a rapidly changing and advancing healthcare system, effective nurse leaders must be able to base their actions depending on the environment and needs identified.

Specifically, Fiedler’s Contingency Theory can be found in use by today’s healthcare leaders.  As healthcare increases in complexity, leadership must advance.  Fiedler’s Leadership Contingency Model outlined a plan for nurse leaders to progress based on the environment.  The three major variables influencing leadership skills include:

1.  “Leader-member relations:  the type and quality of the leader’s personal relationships with followers

2.  Task structure: how structured the group’s assigned task is

3.   Position power:  power that is conferred on the leader by the organization as a result of the assigned job” (Huber, 2010, p.14).

According to Huber (2010), the Contingency Theory states that the leader is most influential over the group when leader-member relations are good, task structure is high, and position power is high (p.14-15).

According the Giltinane (2013), the Contingency Theory and Situation Theories are applicable to the practice of nursing leadership today.  A situational leader must be able to “identify the performance, competencies, and commitment of others, and to be flexible” (p.38).  As healthcare organizations are facing constant change, top-tier leaders must be amenable to the development of different leadership styles based on different (and ever changing) situations. 

Based on the environment, the leader would vary management the approach to maximize outcomes.  An example of leadership based on the Contingency Theory would be the management of specific situations, such as “simple or complicated situations would be best handled through a task-oriented approach such as transactional leadership” (Giltinane, 2013, p.38). 

A specific example of such a situation can be viewed by the management of implementation of Electronic Health Records (HER).  An effective leader would take the complicated situation of transitioning from paper to computerized charting and lead with a task oriented approach.  This may be a transition in leadership style.  The leader would focus on assessment of “follower” or staff skills, identify staff with strong skills, and focus specifically on the task of implementation of computerized charting.  By taking on an active role and identifying staff as resource persons, the leader is remaining flexible and available.  Such a “hands on” presence may not always be necessary, but the leader is adapting their role with staff and on the unit based on the situation experienced. 

Situational leadership gave way to transactional and transformational leadership.  These forms of leadership focused more on the interaction between leaders and followers.  While it was necessary to develop leadership styles based on relationships as is viewed in the transactional/transformational movement, the Situation Leadership Theory offered a foundation for further development of flexible leadership in healthcare.     

References

Collins, J. (Ed.). (2001). Good to great. New York, NY: HarperCollins Publishers Inc.  Giltinane, C. (2013). Leadership styles and theories. Nursing Standard, 27(41), 35-39.

Huber D L 2010 Leadership and nursing care managementHuber, D. L. (Ed.). (2010). Leadership and nursing care management (4th ed.). Maryland Heights, MO: Saunders Elsevier.  201309141311151452293873

The Decision Making Process Applied to the World of Nursing and Health Care

The steps of the decision making process are as follows:

            1.  Identify the Problem

2.  Identify Decision Criteria

3.  Allocating Weights to Criteria

4.  Developing Alternatives

5.  Analyzing Alternatives

6.  Select Alternative

7.  Implement Alternative

8.  Evaluate Decision Effectiveness

So does this transfer to the realm of nursing and, if so, how?  Well the answer is yes.  The decision making/problem solving process can be viewed in the following problem addressed by a nurse manager using the American Nurses Association (ANA) standards to analyze the problem.

1. Identify a management problem.  A management problem is the lack of consistent and accurate monitoring of daily weights for congestive heart failure patients admitted to the inpatient cardiac stepdown unit.
2. Write a problem statement.  Daily weights are a tool for monitoring hypervolemia in heart failure patients.  Daily weights are monitored every morning, obtained by night shift nursing and nurse assistant staff, as a tool for physician monitoring of fluid volume status.  Daily weights are repeatedly not being collected or inaccurately documented for heart failure patients on the unit.  Consistent and accurate daily weights while inpatient offers patient reinforcement regarding the importance of continuing this activity at home after discharge.   
3. Use the ANA standards to analyze this problem.

• Standard 1
• Assessment (What data would you collect?)
• Use of evidence based practice is a core competency for nursing management and professional nursing practice (Roussel, 2013, p.26).  Focusing on evidenced based practice to support the importance of the practice of daily weights, I would collect data related to the importance of accurate fluid management strategies in heart failure patients. 
• According to Albert (2012), the “assessment of hypervolemia is important, because freedom from hypervolemia after hospitalization has been associated with improvement in long term clinical outcomes” (p.23).  Albert (2012) also listed the five signs of hypervolemia as orthopnea, peripheral edema, weight gain, need to increase diuretic dose, and jugular venous distension (p.23).  To promote the best possible outcomes for our patients, accurate daily weights must be collected and documented daily as ordered by the physician and per our unit protocol.  This not only allows for more accurate monitoring during the patient’s hospitalization, it promotes the completion of daily weights post discharge.  As Medicare reimbursement dollars decrease for HF readmissions, health care providers must provide patients with every possible tool to adequately manage their chronic health condition effectively upon discharge.    
• Standard 2
• Diagnosis the cause of the problem (Explain variables that impact the problem)
• The cause of the problem is the inconsistency of nurse versus nurse assistant weighing patients.  A knowledge gap has also been identified.  Some nurse assistants were found to be unaware of the importance of daily weights for disease management.  A knowledge gap was also identified related to the understanding of the importance of comparing the morning’s weight against that of the previous day for accuracy and evaluate if a recheck is necessary. 
• The practice had been that only patients with heart failure or as ordered by physician were weighed every day.  This lead to confusion and the increase occurence of missing patients who were ordered to be weighed daily.  Also, many nurses on the unit viewed daily weights as a “CNA responsibility” and did not follow up with the results of the daily weights.   
• Standard 3
• Identify outcomes (How does this problem impact staff and other departments?)
• This problem impacts the patient, nursing staff, physicians, and health care organization.  The patient is impacted by not receiving the best possible and recommended care.  Nursing staff are affected by not adequately completing physician orders.  Physicians are impacted, as they cannot accurately judge the fluid volume status of the heart failure patient without accurate and consistent weights obtained per orders. 
• The organization is impacted greatly by this problem.  Not only is weighing patients per orders the best practice for the patient, it is in the best interest of the organization.  By promoting healthy behaviors and educating patients, the organization promotes healthy behaviors after discharge.  Healthy behaviors and disease management behaviors improve patient health and decrease the rate of a hospital readmission.  Reimbursement for hospital readmissions for heart failure patients is decreased.  This cost becomes a responsibility of that health care organization.  For the financial wellbeing of the organization, hospital readmissions need to be prevented however possible.
• Standard 4
• Planning (Develop a plan to address the problem)
• As a manager, I want to promote staff involvement and buy in for change on the unit.  Therefore, this problem was brought to the attention of the Unit Based Committee.  As a committee made of frontline nursing staff on the unit, it is a great opportunity to give them the autonomy to initiate a change.  The UBC reviewed the problem and discussed potential plans to improve the problem under the guidance of management. 
• The UBC developed a plan for improvement of daily weights.  Daily weights accuracy and consistency will be improved if all patients are weighed.  This will decrease the “skipping” of patients needing to be weighed.  Improved communication will be promoted between nurse and CNA.  The nurse and CNAs will distinguish who will weigh each patient to ensure the weights are completed in a timely fashion.  Nurses will be re-educated regarding the importance of daily weights and monitoring the weight entered in the chart for accuracy.  CNA education will take place to educate regarding what amount of weight change must be reported to the nurse as well as what changes in weight mean.
• Standard 5
• Implementation (Develop an implementation plan)
• The implementation plan will begin at the next unit staff meeting.  At the monthly unit staff meeting, a representative from UBC will be present to “roll out” the change to the staff with the support of management.  The UBC and management will provide staff with evidence supporting the importance of accurate daily weights.  Feedback will be encouraged and appreciated to improve staff buy in to the change.
• CNA education regarding daily weights will be conducted yearly at CNA skills day as well as immediately via email, at monthly CNA meeting, and at the monthly staff meeting. 
• The unit clerical for each shift will be responsible for checking for incomplete daily weights and reporting findings to the charge nurse. 
• Standard 6
• Evaluation (Develop an evaluation plan)
• The evaluation of the plan will be done daily by the unit clerical (who reports findings to charge nurse) checking for incomplete weights.  Evaluation of the plan will also be done through promotion of frontline staff feedback regarding perceived efficacy of plan.   Lastly, chart reviews offer a concrete form of evaluation.  Daily weights are documented on the vital signs flow sheet in the electronic chart.  Daily chart reviews will be reported to the charge nurse.  A designated UBC member will also review charts weekly and report discrepancies to management. 

So as you can see, the world of nursing closely relates to the world of business.  The ANA standards of problem analyzing is very similar to the steps of the decision making process listed.  The steps of the decision making process can be found in the steps of ANA problem analysis.

References

Albert, N. M. (2012). Fluid Management Strategies in Heart Failure. Critical Care Nurse, 32(2),

20-33.

Roussel L 2013 Management and leadership for nurse administratorsRoussel, L. (Ed.). (2013). Management and leadership for nurse administrators (6th ed.). Burlington, MA: Jones & Bartlett Learning.  

External Environment: Technological Trends Affecting Health Care and Nursing Leadership

Technology and Data Management

The push to transition from paper charting and data collection to Electronic Medical Records (EMR) is an external environmental factor that affected healthcare.  Electronic Medical Records (EMR) must be monitored and managed.  Data collected from many individuals practicing must be integrated, coordinated, managed, and linked with patient outcome measures.  By linking the EMR with patient outcome measures, data is provided for reimbursement for health care services.  The technological trends forced health care systems to become compliant with the advances being made, as it affected reimbursement dollars.  As taught in nursing school, if it wasn’t charted, it wasn’t done.  The data reviewed in the EMR can cause increased, decreased, or denied reimbursement (Huber, 2010, p.781). 

New departments such as data management offices were developed to monitor and implement upgrades and training for documentation programs.  Data management offices must also review documentation for accuracy per guideline expectations (most frequently Medicare requirements).  Health care organizations had to follow the trend and adapt by the implementation of EMR and the development of departments and personnel to support the software.

My organization’s main management information systems used are Healthwise and hCAR (Humana Cares Reports).  The hCAR offers reporting features to assist in managing a team, individual caseload, and monitor productivity.  The purpose of the management information system is to provide useful information to be used in decision making.  According the Huber (2010), the 10 criteria of a management information system include:  informative, relevant, sensitive, unbiased, comprehensive, timely, action oriented, uniform, performance targeted, and cost effective (p.782).

Data base systems are used for physician order entry, view/retrieve lab results, and support the documentation of nursing care.  The goal of data base systems and EMR is to provide a unified electronic record that is able to link clinical and business processes, decrease data replication, and increase the availability and accessibility of information (Huber, 2010, p.781).  The systems used within my organization are Humana Cares Action Tracker (hCAT) and Clinical Guidance Exchange (CGX).  hCAT is a system for tracking actions, intervention, and data for each member.  CGX is a system for documentation of member information, nursing and ancillary service notes, call outcomes, care plans, medical history, etc.  The goal of the organization is to merge the two data base systems into one system to increase efficiency and accuracy of documentation.

I experienced the implementation of EMR in my previous position.  Management was responsible for being complaint with training and knowledgeable of technology.  As I switched organizations this fall, I have been able to newly experience the affect of technology with a different company.  External factors will always affect health care organizations and the expectations of management.  It is important that management stay supportive and knowledgeable of change and promote compliance by their employees. 

Huber D L 2010 Leadership and nursing care managementHuber, D. L. (Ed.). (2010). Leadership and nursing care management (4th ed.). Maryland Heights, MO: Saunders Elsevier.  

Ethical Dilemma: The Impaired Nurse. What is a manager to do?

Substance Use Disorder of Nurses:  Ethical Dilemma or Disease Process?

According to DeClerk (2008) “Substance use disorder is a progressive disease which untreated continues to worsen leading to the addict’s decline physically, psychologically, emotionally, and eventually their death” (p. 22).  Substance abuse is considered an occupational hazard of nursing affecting 10% of nursing professionals.  6% of nursing professionals with substance use disorder experience interference with their ability to practice (Michigan Nurse, 2008).  Impaired nurses are a danger to not only themselves, but coworkers and patients in their care. 

Behaviors indicative of substance use disorder must be identified in order to confront a nurse believed to be impaired.  Fleck (2012) recognized behaviors suggestive of impairment as follows:

Unkempt appearance, shakiness, tremors, pinpoint pupils, slurred speech, flushed face, bloodshot eyes, smell of alcohol on breath, injuries such as bruises/burns/wounds, increased physical complaints, increased reliance on prescription medications, impaired motor coordination, personality changes, overreaction to criticism, professional and social isolation, medication errors, illogical or absent documentation related to controlled substances, discrepancies in documentation related to controlled substances, excessive absences or tardiness, difficulty focusing on task and forgetfulness, absent from unit without explanation, and patient complaints of ineffective pain relief after being medicated. (p.22).

In addition to the list of behaviors offered by Fleck (2012), DeClerk (2008) offered the following signs and symptoms of substance use disorder:

Long trips to the bathroom after being in medication/narcotic cabinet, volunteering for overtime or showing up at work when not scheduled, unreliability with appointments and deadlines, mistakes due to inattention and poor judgment, heavy wastage of drugs, frequently breaks and spills drugs, usage of maximum PRN dose when other RNs have used less, wears long sleeves when inappropriate, irritable with patients, sleepy or dozing off while on duty, and defensive when questioned about medication errors. (p.12-13).

So I recognize it, now what?

The American Nurses Association (2013) believes that the nurse’s duty of compassion and caring extends to self and colleagues as well as patients.  It is an ethical responsibility to provide care to the impaired nurse.  A substance abuse problem displays neglect of self.  The ANA supports peer assistance programs, such as the Kentucky KARE program.  The Kentucky Board of Nursing has a program to identify, assist, and monitor nurses whose ability to practice is impaired by substance use disorder (Kentucky Board of Nursing, 2013). 

It is the ethical obligation of a coworker to report an impaired nurse as much as it is an ethical responsibility to not abuse substances.  Nurses have an obligation to report impaired colleagues.  Friendship, concern for colleague’s reputation, and stigma associated with reporting can cause hesitance to report.  While many factors dissuade nurses from reporting questionable behavior of a colleague, legal and ethical duty require the nurse to uphold state and federal laws pertaining to nursing practice.  “The nurse has a legal, as well as professional, responsibility to report an impaired colleague, or any nurse to the Board that is suspected of misusing or misappropriating drugs placed in the custody of the nurse for administration or for use of others” (Fleck, 2012, p. 23).    

Reporting an impaired nurse should be done following the facility’s policies and procedure.  The staff must report findings objectively to the immediate supervisor (Fleck, 2012).  Key factors to remember while confronting and reporting an impaired nurse include remaining objective, non-accusatory, non-threatening, non-confrontational, and maintain confidentiality (Michigan Nurse, 2008).  Substance use disorder is dangerous and can lead to death if untreated.  According to DeClerk, drug addiction is often discovered in the workplace last and has already affected other aspects of the individual’s life (2008).  Identifying and reporting an impaired nurse is necessary to protect the health and well-being of the nurse and patients in their care.    

References

American Nurses Association 2013 Impaired nurse resource centerAmerican Nurses Association (2013). Impaired nurse resource center. Retrieved from http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/Work-Environment/ImpairedNurse 201307101146231206593633

DeClerk P 2008 Recognizing the chemically impaired nurse.DeClerk, P. (2008). Recognizing the chemically impaired nurse. ASBN Update, 12(4), 12-13.  201307101058261772331715

Fleck P L 2012 HELP! I think I know a nurse who may be impaired!Fleck, P. L. (2012). HELP! I think I know a nurse who may be impaired! KBN Connection, (31), 22-23.  20130710104723225020647

Kentucky Board Of Nursing 2013 KARE for nurses programKentucky Board of Nursing (2013, May 8). KARE for nurses program. Retrieved June 10, 2013, from http://kbn.ky.gov/kare/ 20130710105221110514283

Michigan Nurse 2008 do's and don'ts of helping the impaired nurse.Michigan Nurse (2008). The do's and don'ts of helping the impaired nurse. Michigan Nurse, 81(6), 15.  

Personality Types: What makes a good nurse?

A nurse must be kind, gentle, patient, able to multitask, have strong critical thinking skills, and confident to make decisions and act quickly under pressure.  Much is required of nurses.  It is not a job meant for everyone.  Personalities and characteristics must support the skills necessary to thrive in the field of nursing.

 

Our personalities shape our behavior and interpersonal relationships.  The MBTI personality test is a tool for self evaluation and awareness of one’s strengths and weaknesses.  It can help us understand why we think, act, and react the way we do.  The psychological types evaluated in the MBTI personality test include:  extraversion versus introversion, sensing versus intuition, thinking versus feeling, and judging versus perceiving.  The test indicates the differences in personality for gaining energy, becoming aware of information, making decisions, and dealing with the world (Roussel, 2013, p.486).  These differences can lead to strengths in weaknesses in providing patient care and functioning as a nurse. 

A nurse leader must understand their personality types as well as those of the team.  This allows for a nurse leader to be a more effective leader, especially in high stress situations, based on the combination of specific personality traits.  So the question remains, do certain personality types make better nurses?  The following personality types (based on results using the MBTI tool) are thought to be compatible with the nursing career:

ESFJ (Extrovert, Sensing, Feeling, Judgement) = “the Supporter”

ISFJ (Introvert, Sensing, Feeling, Judgement) = “the Defender”

ISFP (Introvert, Sensing, Feeling, Perception) = “the Artist”

ENFJ (Extrovert, Intuition, Feeling, Judgement) = “the Mentor”

ENFP (Extrovert, Intuition, Feeling, Perception) = “the Advocate.” (My Personality Info, 2013).

The personality type ESTJ (Extrovert, Sensing, Thinking, Judgment) is typically good for nurse administration career paths (My Personality Info, 2013).  Introvert versus extrovert, sensing versus intuition, and judgment versus perception are equally represented as personality traits recommended for nurses.  While different combinations of these characteristics comprise a personality type recommended for nurses, thinking versus feeling were not equally represented.  Nurses (aside from the nurse administrator personality) rate higher for feeling than thinking. 

The thinking versus feeling component affects decision making.  Thinking versus feeling represents whether logic and consistency or people and circumstances affect decision making.  Nursing is a job of providing care for people and their circumstances.  Care must be provided logically, but is individualized based on the patient.  Personal care is a factor in decision making more often than logical care.  The personality career recommendation results of My Personality Info (2013) suggests that feeling plays a stronger role than thinking on the personality and decision making of a nurse.

The relationship between personality trends and career paths offers an interesting opportunity for us to explore what brought us to the career path we chose.  While nurses come in all shapes, sizes, and personalities, there may be reoccurring trends in personality.  Understanding self and others provides leaders with tools to effectively lead by building strong working relationships.  By better understanding what drives nurses to do the job they do, nurse managers and leaders are able to better understand how to support their staff to thrive in their environment.  The success of the manager to develop and lead the team can translate into greater success for the organization.      

References

My Personality Info 2013 My Personality InfoMy Personality Info (2013). My Personality Info. Retrieved September 12, 2013, from http://www.mypersonality.info/personality-types/careers/

Roussel L 2013 Management and leadership for nurse administratorsRoussel, L. (Ed.). (2013). Management and leadership for nurse administrators (6th ed.). Burlington, MA: Jones & Bartlett Learning.  20130914130953335672974

Stress management and nurse burnout: The role of management

Stress is a physical, mental, physiological, or spiritual response to a stressor.  A stressor is an experience in a person-environment relationship evaluated by a person as taxing or threatening the sense of wellbeing (Huber, 2010, p.131).  Stress is a subjective experience of an individual in response to their environment.  Work overload or underload can lead to physical exhaustion, emotional exhaustion, attitudinal exhaustion, and feelings of decreased accomplishments.  This experience is recognized as burnout.  Burnout is a term used to describe a response to chronic emotional stress.  Huber (2010) characterized burnout by three components:

1.       Emotional and/or physical exhaustion

2.      Lower job productivity

3.      Over depersonalization. (p.132).

“Nursing burnout is the terminal phase of the individual’s failure to resolve work stress or accumulated inability to cope with day to day job stress.”(Huber, 2010, p.132).  The high stress/emotional work environment, real or perceived short staffing, increased workload, increased concerns about client safety and the nurses' ability to cope and deliver adequate services can contribute to stress and burnout (Huber, 2010).    

So we understand burnout…how does that affect the manager or the institution?  Both the nurse and the employer have a stake in the management of stress and stressful environments.  High levels of job stress/burnout can affect the following:

§  Individual nurse health (a healthy nurse is an effective and reliable nurse)

§  Job satisfaction (a satisfied employee is more productive)

§  Absenteeism (adequate hospital staffing is vital to the institution to be able to provide patient care)

§  Turnover (hiring and training new nurses is timely and expensive $$)

§  Client welfare (the goal of healthcare organizations is often to provide quality patient care maintaining the client welfare as the top priority) (Huber, 2010).

An organization needs satisfied customers to remain competitive.  Nursing personnel

constitutes the largest group of healthcare providers in the United States (Huber, 2010,

p.319).  With nursing personnel making up the largest part of the healthcare workforce,

healthcare organizations cannot thrive without healthy, happy, and high functioning

nursing staff.  

Empowerment of staff nurses has been related to increased work satisfaction and lower burnout rates (Huber, 2010, p.130).  Stress reduction techniques and promotion of autonomy is important for a nurse manager to understand.  It is the responsibility of the management and institution to promote stress reduction for the nursing staff and hospital employees.      

 Huber, D. L. (Ed.). (2010). Leadership and nursing care management (4th ed.). Maryland Heights, MO: Saunders Elsevier.  

Human Relations Movement Impact on Nursing/Healthcare Management

The Human Relations Movement, beginning in the 1930s, sparked a change in focus for management.  Organizational management realized that the satisfactions and dissatisfaction of employees affected productivity.  Management focused on the needs of employees.  Through the satisfaction and retention of employees, an organization is able to increase productivity and decrease costs.  An organization saves money by retaining employees and not having to spend resources on training/orienting new staff.  Experienced, satisfied staff tend to work harder and better!  Change in the workplace and attention paid to satisfaction/dissatisfaction of employees makes employees feel appreciated.  It was in the organization's best interest to manage employees while focusing on their needs.  

Drucker (2001) displays the importance of the Human Relations Movement in his writings.  He wrote, while the manager represents power, management is also about human beings.  A manager should focus on the needs of the employee.  As a result, management is able to make "strengths effective and weaknesses irrelevant"(p.10).  How has the Human Relations Movement impacted the current role of nursing management?

The satisfaction and dissatisfaction of staff within a healthcare system is a reflection of the management in place.  Surveys are taken regularly of nursing staff to evaluate their job satisfaction.  Surveys measure areas of satisfaction such as opportunities for advancement, satisfaction and support with management, opinions being heard and respected, satisfaction with pay, etc.  The Human Relations Movement set the stage for healthcare workers/nurses to voice satisfactions/dissatisfactions. 

In order to be able to offer satisfying management, a nurse manager must understand what is valued by the employee.  Roussell (2013) offered characteristics of best bosses and worst bosses from the viewpoint of nurses:

BEST BOSS

-understands by strengths and weaknesses

-available and accessible

-open to feedback

-expects effort and conscientiousness, not perfection

-open to input from the group

-positive and upbeat

-'walks the talk'

-keeps department's best interest at heart

-cares about how the patients are treated

-high standards, sticks to values

-creative, willing to take risks

WORST BOSS

-poor listener

-only offers negative feedback

-doesn't want my opinion

-wants to look good to his boss at all costs

-unavailable, inaccessible

-negative, always in a bad mood

-rigid and defensive

-unaware of the feelings of others

-listens to gossip

-has favorites

-has no vision

(p.71).

The Human Relations Movement gave power to the employee experience.  A satisfied employee is a productive employee.  Nursing management must offer attention and focus to the feelings of satisfaction/dissatisfaction of their employees.  A nurse manager who is positive, upbeat, leads by example, a patient and employee advocate, trustworthy, and open to feedback will improve nurse satisfaction.  The satisfaction of nurses with their workplace and management is important as a result of the Human Relations Movement of the 1930s.  The values and priorities identified through the movement laid the ground for an effective nurse manager to lead efficiently by retaining staff.  Happy and experienced staff provide higher quality of care to the patient, who is the customer of healthcare organizations. 

 "A result of business is a satisfied customer"(Drucker, 2001, p.12).   

     

Drucker, P. F. (2001). The essential Drucker. New York, NY: HarperCollins Publishers. 

Roussel, L. (Ed.). Management and leadership for nurse administrators (6th ed.).  Burlington, MA: Jones & Bartlett Learning.