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Knowledge  Article
Stepping Outside of `Yesterday Thinking’:
Preparing Nurse Managers
for a New World Order
By Franklin A. Shaffer, EdD, RN, FAAN
Nurse managers of today are the linchpins to retaining nurses,
and ultimately to the success of any healthcare organization. Yet
despite
their importance, training is often put aside for financial reasons
and time constraints. If we want to retain nurses, it is essential
that we train excellent nurse managers. This training must come
in a way that is new, innovative, and effective. “Yesterday
thinking” will not work, nor will the training methods of
yesterday.
A new day in nursing isn’t on the way — a new day is here.
Hospital systems that learn how to adapt quickly and make the changes
necessary will survive, and those that are entrenched in old methods
will find themselves in staffing difficulties that will only continue
to increase at exponential rates. Doing things “the way we’ve
always done them” will get us nowhere. The facilities that
place nurse management training as a priority are finding a direct
correlation to their low turnover rate in managerial and staff nursing
positions, and to their leadership development and succession planning.
Falling short
Sixty-one percent of nurse managers today report that they do not
receive ongoing management development. They
believe that they need training in business, staff retention, coaching,
mentoring,
patient care systems and communications. Most nurse managers, with
degrees in clinical care, lack the management, communication, problem-
solving, and negotiating skills necessary to retain a staff whose
age span spreads four decades, within a mosaic of cultures. This
is probably why some 77% percent of today’s hospitals feel
that they won’t be able to fill their leadership positions. VHA
research reveals a 44% turnover rate among the Chief Nurse Officers
at member healthcare organizations. Thinking
that we don’t
have to train nurse managers is a death knell to our success. Considering
today’s leadership gap — now, more than ever — nurse
managers need the necessary tools to succeed. And above all, they
need buy-in
on all levels from the executives supporting them.
Salary
Nurse managers lack support in many areas, beginning with salary.
Clearly, salary is not adequate enough to retain nurse managers,
with 53% of nurses surveyed by the Student Nurses Organization
experiencing a nurse manager shortage, and of that 80% say compensation
is influencing this shortage.
Technology
But adequate salary alone will not entice qualified nurse managers
to a job that requires continual progressive technological efforts,
if organizations want to thrive. The organization and the nurse
manager’s success are dependent on technology that stays
abreast of the times. According to one nurse survey, 87% say technology
has had a positive impact on patient care delivery.
Technology systems are critical for nurse managers because they
automate and standardize communications, reducing the chances of
making mistakes. In a knowledge-sharing enterprise where evidence-based
decisions are made objectively by software, turf battles and professional
differences can be made less divisive. When used appropriately, technology
can be critical to overcoming some of the perceived downfalls of
working in healthcare, and can aid the recruitment, retention and
motivation of qualified staff. For these reasons, every technology
decision becomes a work force strategy decision.
What it costs to replace a nurse
When confronted with the relatively minimal cost of training a nurse
manager, organizations would be best to ask themselves this question:
what does it cost to replace a single nurse? The VHA estimates
the total turnover costs to an organization approximately $50,000
for each nurse lost. Good nurse
managers beget good nurses, and those less likely to leave. With
the steady
exodus of nurses, doctors
are becoming frustrated and taking their patients elsewhere or
hospitals are canceling cases and closing units. Hospitals that
don’t see this as a wakeup call haven’t learned from
shortages in the past. These aren’t just nursing issues anymore;
they are issues for all stakeholders in the healthcare system.
The priceless value of training nurse managers
The nurse manager is on the frontline every day, and the bricks and
mortar to the public, and in essence, is an important part of any
marketing department. Let’s not forget that today’s consumer
is well informed and demands quality care. That service lies in the
hands of a competent nurse manager. Competent leadership is cost-effective
patient care. A recent study shows that 40% of nurses believe the
single most important thing that nursing leadership can do to assume
delivery of high-quality, safe, cost-effective care is to have communication
with and understanding for the needs of the direct patient care providers. The
same study says that 22% believe that leadership is needed to set
standards for care and assure competence of caregivers.
Intellectual capital
A paradigm shift from focus on skills measurement to intellectual
capital is necessary for today. The new millennium requires that
we step back and evaluate employees beyond ROI and measure the intangible
contributions in dollars and cents. Today, almost any organization
can gain access to resources. But business today is shifting more
and more from focus on services, to knowledge. What differentiates
companies now is their intellectual capital, their knowledge, and
their expertise - not the size and scope of the resources they own
and manage. Saratoga Institute, a subsidiary of Spherion and owned
by PricewaterhouseCoopers, has done extensive work on tying the financial
impact of intellectual capital and other value added attributes that
employees bring to the table. When a nurse leaves your hospital you
are losing intellectual capital which can not always be replaced
by another body and creates a void in customer service.
Leadership training scarce
For the past 20 years or so, nursing leadership has been striving
to elevate the preparation of nurse managers, in most cases requiring
minimal preparation at a bachelor’s degree, but preferring
graduate preparation. Recently the growing shortage of experienced
or qualified nurses available for leadership is forcing more and
more hospitals to place nurse managers into these positions with
associate degrees. Once they are placed in their new role, they
are faced with learning mainly on the job, or by trial and error.
The typical training of nurse managers today, including orientation,
is frequently inadequate and not provided by an experienced nurse
manager. Periodic courses, many of which are taught by non-nurses,
are not tailored to meet the learning needs of today’s nurse
manager. Faculty frequently lack the insight to make inferences to
the nursing manager’s role or practice, bringing in outside
or canned programs that once again are not specific to role responsibilities
or the accountabilities of nurse mangers. With a downward shift in
federal funding, many formal academic programs have been downsized
in favor of graduate preparation in clinical specialties. Schools have opted to discontinue any programs
preparing nurse managers or nurse executives, and/or have dropped
CE courses or post baccalaureate certificate programs. This has caused
many nurse mangers to seek academic preparation through a school
of business or other programs, leaving a decrease in the number of
nurses graduating with preparation in nursing administration. The
remaining nurses graduating from schools of nursing are coming from
the associate degree or BS programs and these programs usually only
offer one or two courses on leadership. Specialization for the nurse
leader is left appropriately for the graduate level.
Portrait of a nurse manager
The average age of a nurse manager is 46-50 years, and
they have different values and norms about work, and the ways of
working,
based on their experience. They are sometimes locked in their own
version of “yesterday thinking.” Their staff are in
their twenties, thirties, forties and fifties, each age-group with
different expectations and different perspectives on the nursing
experience – not to mention different attitudes about working
for employers altogether. Most hospitals have multicultural staff,
as well. Not only do we have generational problems, but we also
have value and cultural differences that must be taken into account.
It is critical that nurse managers get essential training on how
to handle each staff member within the context of that individual
person’s reality. Nurse managers need tools that can be used
to blend different and differing employees into a functioning team
that will provide the kind of care the consumer of today expects.
This is no easy task as we face for the first time four different
generations in our hospitals each with different values and norms.
One size does not fit all
Studies have proven that the majority of nurses leave their current
place of employment because of their nurse manager. Eighty-four
percent of nurses leaving or consider leaving their jobs are doing
so as a result of their relationship with their nurse manager. Talent
Keepers surveyed 39 leading organizations and found that 100% of
the respondents reported that the immediate managers are
a factor for employees leaving and often the main factor.The most
cited reasons employees leave are “trust,concern and support
from immediate manager”. While the manager is so critical
to reducing employee turnover,only 21% of the managers believe
that their actions and skills significantly impact on retention.
With all of the focus on recruiting nurses today and the application
of such methods as paying for the leases on their cars, sign-on
bonuses, etc., there is little focus on how to keep nurses after
they’ve signed on. Keeping good nurses is a factor of spending
the time and energy to find the right fit for your organization
in the first place, and understanding what today’s workers
expect. One size does not fit all when it comes to retaining staff,
and a nurse manager above all others, must be trained to understand
this and deal with it by creating the kind of environment that
will retain valuable staff. Most people are attracted to a organization
because of the benefits or other tangibles but people stay because
of relationships .There is a direct correlation between managerial
development and reduction in turnover. Manager training is not
optional.
Nurse managers need to take the time to sit down with prospective
employees and look at their career portfolios on the way in; see
what their career ambitions are, where they are headed, what they
expect. The time spent upfront is a small price to pay for finding
a nurse that will be satisfied with your organization and will
stay. When the wrong fit is hired, leaving the organization within
the all too often typical six-month timeframe, you face the loss
of not only this one new employee, but the loss of stable long-term
employees, as well. When turnover rate is high, morale declines
with the pressure placed on existing performers. In the end, you
lose both the good performer and the poor performer, all at once.
The upfront effort of recruiting the proper staff, and retaining
them with well trained nurse managers, is critical.
In addition to the stressors already on nurse managers to manage
multi-generational staff, the demographics of the workforce are expected
to undergo a dramatic shift in years to come that will leave a serious
shortage of workers. Already, 11 percent of the active workforce
is over 56 years old, a percentage that will grow steadily as Baby
Boomers age. On the heels of retiring Boomers, the much less populous
Generation X (now ages 25-38) will provide a shrinking pool of prime-age
workers. And even with a modest increase in workforce population
among Generation Y (now ages 16-24), there will simply not be enough
young workers to fill the void that will be left.
Expectations of today’s nurses
The expectations of today’s nurses are a reflection of what
most workers want today. They are not the company-loyal employees
of the past. They are loyal to self. They seek to improve and expand
on their own potential while in your employ, but if they don’t
see themselves growing, they will all too soon be gone. In addition,
the workforce of the new millennium is comprised of a new race of
nomads who seek greater balance between work and home. According
to the U.S. Bureau of Labor Statistics (BLS), in 1997, an estimated
12.5 million workers were employed in “alternative work arrangements” out
of a total workforce of 126.7 billion. This emphasis on contingency,
temporary workforce provides workers with more choices and/or autonomy
without compromising any of the attributes of professionalism. The
BLS study highlights the growing preference for unrestrained work,
and predicts that the major employer of the future will be self.
Unless nurse managers can provide what employees seek – including
pulling from this source, and/or allowing alternative arrangements
— they may continue to face a revolving door of staff turnover.
Managing a multi-generational and multi-cultural workforce requires
managers who have in-depth training to acquire the skills necessary
to motivate a diverse workforce into a cohesive team.
Career lattices vs. ladders
One of the ways a trained nurse manager can provide career growth
for today’s nurses is to think in terms of career lattices
rather than career ladders. The nurse manager must find ways nurses
can move laterally toward their career goals. This can be as satisfying
as upward movement, but requires the nurse manager to be in tune
and educated about each employee’s ambitions and goals. Today’s
trained nurse manager will understand that career development requires
a new way of thinking and expressing job requirements. Emphasis
will shift from trying to motivate, to just keeping up with the
career and professional development needs of staff. Competency
assurance begins with managerial readiness for the new workforce.
Win-win scenarios
Today’s employees understand that the better they become as
workers, the better it is for the organization. In their role as
career counselor, nurse managers have to be able to create win-win
scenarios with employees that are increasingly assertive and demanding
about what they want. Also in this new line of thinking is the ability
to “get over” the fact that some nurses will move on,
despite how well you try to meet their needs. Do not burn bridges.
Instead, retain them in a database of potential employees. They may
boomerang back to you, and are still of value.
Employee attitudes since 9/11
Is important to put nursing work expectations in the context of changing
employee attitudes since 9/11. More than 4 in 5 employees have
re-examined their priorities since the attack, and have decided
they need to spend more time and energy on personal, family, and
community activities, and less time on their jobs. In addition,
employees are showing the highest level of workforce commitment
in five years. Yet despite the high
level of commitment, 23% don’t
believe their organizations are going to be able to recruit and
retain the best talent, 30 % don’t have faith in the organization’s
ability to reduce costs, and 35% don’t believe their organizations
will be able to improve the compensation and benefits package in
2002. Some organizations may experience a “halo effect” whereby
employees are giving their employers the benefit of the doubt,
but they can easily be lured away when the external environment
changes.
Nurse manager boot camp
One of the best ways to give busy nurse managers the tools they need
for good management is a short, high-powered intensive training,
with ongoing support afterward. One model if such a program is
Cross Country University’s boot camp, a program of Cross
Country, Inc. It is an example of “just in time training
for an in time learner.” Our industry could use many training
methods of this nature. This training prepares the managers with
the skills they need now and stimulates them to achieve higher
attributes.
Cross Country’s boot camp for nurse managers, provides an
intense, ongoing learning experience designed to specifically help
transform an excellent clinical nurse into a frontline manager of
nursing services. Nurses who receive the training begin their boot
camp experience with an in-depth psychometric assessment of their
capabilities and weaknesses. The areas assessed include the abilities
to: coach and counsel; effectively communicate; influence and negotiate;
manage change; perform management; set goals and standards; manage
conflict; problem-solve and make decisions. The accuracy in determining
each camp attendee’s needs determines the effectiveness of
tailoring the training for that particular nurse manager.
The term boot camp fairly well defines the experience – five
full days, twelve hours each – with additional workshops available
for the stout of heart. Networking is encouraged between faculty
and boot camp attendees (“recruits”) both during mealtime,
3 times a day, and on special evenings set aside for such. The training
is rigorous with classes held on topics that include: workforce planning,
staffing and scheduling; leadership vs. management; budgeting; motivation
and morale; critical thinking and decision-making; planning, and
more.
Ongoing commitment
The success of the program is attributed to the long-term commitment
elicited from recruits. To be effective, learning must be ongoing
and reinforced. To achieve this goal, recruits are asked to sign
personal commitment agreements that stipulate “what, how
and when” knowledge gained at boot camp will be applied over
the 30, 60 and 90 days following training. Recruits are obligated
to submit monthly managerial reports documenting their utilization
of skills gained at boot camp. These reports will be directly applied
to the camp graduate’s performance evaluation by his or her
immediate supervisor on the job. In addition, boot camp graduates
contribute to an ezine published at regular intervals for their
continued growth and receive ongoing mentoring through emails and
chats scheduled on the Web. Camp graduates can earn up to 55 credits
of continuing education contact hours and will shortly be able
to earn academic credit for attending. In addition, the advanced
track is developed in collaboration with graduates and the Forum
on Healthcare Leadership and graduates attend their specially designed
sessions as well as the national conference.
Redefining a nurse manager’s
role
After training nurse managers, it is essential to redefine their
role. We need to rethink the necessity of the jobs they are responsible
for today, assigned under yesterday’s thinking. Right now
these jobs may include scheduling, budgeting, and management of
up to five units, along with the need to attend many meetings.
If we want to transform the industry, nurse managers should ultimately
become mainly the overseers of career and of care, only. Most importantly
the manager of tomorrow will facilitate career development initiated
at the pre-employment stage for each and every employee. We need
to create a new paradigm where employees are transformed from assets
to investors, and where reciprocity is key. So the principle is
seek great job fit, train early and consistently and hold managers
accountable.
Nurse managers can effect change
Nursing managers can facilitate the changes needed in our organizations
if properly trained and allowed to fill the shoes that the new
millennium requires. Ultimately, they can begin to effect change
in the nursing profession, and in the healthcare arena. To do so,
the nurse manager should be trained in ways that strengthen him
or her to fulfill roles that include:
- Negotiator
Workers
expect a transactional environment. A nurse manager must be able
to meet the demands
of the gamut of ages, from
the younger more upfront employees who “want what they
want” because
they see it as their right, to the senior staffers who are willing
to submit to the company line, yet will hold in the resentment
only to blow up one day, and perhaps quit. It requires a strong,
well-trained
nurse manager to negotiate with three or four generations of
staff at the same time so that all of them to get what is in
it for them,
while the nurse manger gets what’s in it for the organization.
- Career planner
Job sculpting should be a
part of a nurse manager’s
assistance to his or her staff, creating individuals to be creative,
and seeking new opportunities to be proactive in the changing
world of work. A trained nurse manager knows that this planning
starts
before he or she needs to choose a successor. Future nurse managers
are molded, with career and culture fit in mind, by a nurse manager
who has the destiny of the organization in mind.
- Mentor
Nurse
managers face a steep challenge in a world where there is 40% turnover
in nurse executives.
This turnover
provides
an unstable or inconsistent environment for nurse managers who
often do not have the privilege of being mentored. Nonetheless,
the nurse
manager who must interface with so many other departments within
the organization must be able to serve as the voice of nursing.
- Facilitator
Just of few of the aspects
of this critical role include: building teams by using decision
making and conflict
management;
monitoring individual performance; managing collective performance;
and finally, managing organizational performance. The frontline
strategist nurse manager must be able to facilitate good nursing
practice by
removing barriers, whether that calls for collaborating, compromising,
or cooperating.
- Coordinator
As coordinator, trained
nurse managers will be able to manage projects, design work,
and manage across functions.
They must have true multi-tasking capabilities with the ability
to acquire the resources to deliver care consistently and efficiently
while maintaining high quality patient outcomes and managerial
benchmarks.
- Director
Visioning, planning, goal setting, designing,
organizing,
and delegating effectively, should be part of what the new millennium
nurse manager can accomplish. He or she should be able to influence
the team to believe in and achieve the hospital’s vision,
and instill a desire for them to be all that they can be.
- Producer
While wearing this hat, the
nurse manager should be able to work productively while fostering
a productive work
environment,
and most importantly, manage time and stress.
- Broker
Since nurse mangers must interact
with all levels of the organization, they must master the ability
to present
ideas, build and maintain a power base, and ultimately, negotiate
agreements
and commitment.
- Innovator
The nurse manager is unafraid
to live with change, can think creatively, and is a master at
creating change.
Add to this list key competencies such as achievement orientation,
analysis, assessment, awareness, computer literacy, exploration,
goal setting, information identification and collecting, interpersonal
skills, networking and oral communications, perseverance, self-management,
strategic thinking, and written communication abilities — and we
will just be starting to describe the nurse managers needed for the
new world order.
The first line manager is the glue that holds the hospital together,
and it takes a great deal of effort, skill and experience to do the
job right. A small investment in training nurse managers now will
pay off in big dividends for the nursing department and hospital
down the road. The training of good nurse managers is not merely
an opportunity to gain another strategic advance over competition;
it is necessary for staying in business as a viable entity in years
ahead.
Franklin A. Shaffer, EdD, RN, FAAN, is President , Education and
Training Division and Chief Education Officer of Cross Country University,
a division of Cross Country, Inc., the largest supplemental staffing
company supplying healthcare professionals to over 3000 U.S. hospitals.
For more than 30 years, he has been involved with the preparation
of nurse managers, and was recently inducted as a fellow of the American
Academy of Nursing.
This article was written by Franklin A. Shaffer, Ed.D, RN,
President, Education & Training Division, Cross Country Inc,
Chief Education Officer, Cross Country University and originally
appeared in Nurse
Leader July/August 2003
© 2003 Cross Country Staffing
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