A Nurse's Viewpoint
A different course
By Roberta B. Abrams, RNC, MA, LCCE, for HealthLeaders.com, Feb. 11, 2002
The legend of Sisyphus revolves around a man who offended the gods, and was therefore compelled to spend eternity rolling a huge boulder up a steep mountain. As soon as the boulder reached the top, it would plummet to the base, and the Sisyphean chore would begin anew.
The current nursing crisis is a depiction of the legend of Sisyphus. The boulder is the traditional mode of dealing with nurses and nursing. The Sisyphean role is portrayed by hospital administrators. It won't work. Rolling up the usual array of salaries, benefits, and responsibilities is a Sisyphean exercise. Not only will it not go anywhere, but the backslide is likely to resemble an avalanche, and result in casualties.
The current crisis in nursing has attracted widespread attention. A poll done by Vanderbilt University Medical Center's School of Nursing reveals that 80% of Americans know about the crisis, and 93% of those individuals believe that it jeopardizes healthcare quality. Federal and state legislatures are moving forward with bills to provide scholarships and to provide other incentives to attract new nursing candidates. California has legislation to mandate staffing levels.
All that is well, good, and necessary. It is not enough. The only thing that is more important than attracting new folk to nursing is retaining the ones that we have. Otherwise we have an inverted funnel, with a small stream of new nurses joining the work force and a torrent of experienced nurses leaving. Let's focus on a key issue for retention from A Nurse's Viewpoint.
One major key is the leadership group. A study of nurses by the Nursing Executive Center found that 90% of nurses who were dissatisfied with their managers were contemplating leaving that facility. In previous columns I have suggested opening dialogs between dissatisfied nursing staff and their managers. The feedback that I have received documents this as an exercise in futility. Dysfunctional managers are just that: "dysfunctional". They either fail to hear their staff, or they are unwilling or unable to ameliorate the situation.
The staff have become so stressed by the morass of clinical issues including mandatory overtime, their inability to provide requisite levels of care, inadequately prepared assistive personnel, and inadequate reimbursement, that they are unable to cope with perceived deficiencies in their leaders.
Many, but not by any means all, of the successful "head nurses" of the past were managers. They took direction from hospital and nursing administrators and did as they were told. They managed time sheets, supplies, staff, and patients. They adhered strictly to rules and policies. They neither asked questions, nor did they encourage others to question them.
For eons this model was functional. When new staff came to the unit, they were encouraged to comply with existing practice patterns. "We've always done it that way" was sufficient reason for any policy or procedure. The model worked then. It no longer does.
Many hospital administrators today are functioning with a dysfunctional "bottom line mentality." To a certain extent, that's understandable. Many, if not most, of today's healthcare facilities are dealing with reimbursement issues and a plague of paperwork related to third-party reimbursement and regulations. They have been so focused on those issues that they've failed to give institutional leadership issues needed attention. Continuing that focus will result in an institution whose reward will be its demise.
The first step in healing units plagued with excessive turnover is to find leaders (not managers) who will nurture the unit staff. Those leaders need to initiate staff meetings, covering all shifts. The focus of the meetings is to elicit from staff their definition of the unit's problems. Staff members are then facilitated in prioritizing the problems, and their input sought is in developing solutions with realistic timelines. It is essential that the leaders make no promises that they cannot fulfill. Staff nurses have had more than their fill of vacuous promises. Their ability to trust has been severely damaged. The promise, and the timeline, must be real. The commitments must be honored.
The unit leaders needs to be viewed by the staff not only as nurturing, but also as credible and action-oriented. The leaders must be visible - to all staff, not just one or two shifts. They must learn as much about the staff as possible and help them to learn about each other. By so doing, the leaders facilitate the unity of commitment and purpose that is key to appropriate unit function.
To be successful, the leaders of the clinical units should join forces with other facility leaders to ensure that the needs of the staff are understood, and that the time and resources to meet the needs are secured. Those who are able only to view this plan from a bottom-line perspective need to be evaluated regarding their continued value to the organization.
The upper echelon of the hospital need to be committed to real leadership. The new leaders need to be brought to the organization with a clear commitment to the following attributes:
Leaders have vision. They are aware not only of what is happening today, but are attuned to what will be coming tomorrow. They work with their staff to prepare for what is and what will be. Leaders understand the need for continuous process improvement. They encourage subordinates to continuously look for ways to do better at what they do.
Leaders are proactive. They collaborate with peers and staff to ensure that their unit or facility is prepared for things to come, whether that is a change in the care delivery system, new care procedures, or new actions from government, regulatory, or reimbursement sources.
Leaders are change agents. They understand that the only constant is change. They not only prepare themselves for change, but work with others in advance of and during change to minimize the threat and enhance the benefit. They seek new opportunities for themselves and for team members which enhance personal and professional growth.
Leaders are committed to their own professional and personal improvement. They seek mentors who can assist them with growth processes. They read, attend courses, dialog with colleagues - all focused on their own growth, and that of colleagues, team members and the facility.
Leaders delegate appropriately. They know the value of teamwork. They recruit and prepare their team members to become future leaders. They work with their staff to seek desired outcomes for the unit or facility that they lead. They ensure that the staff are willing and able to work together, and have the tools to secure desired outcomes. Then they encourage the staff to proceed without micro-management.
Leaders focus on the "big picture"- aware not only of activities within their own facility, but of those in the community in which they live, and the profession to which they belong. They are active both in professional and community organizations.
Leaders are facile communicators. They regularly initiate communications with their team members. They meet both formally and informally with staff, patients, and other customers. They share information ensuring that staff have knowledge of activities related to healthcare delivery and to the community. They also elicit feedback from customers related to facility activities. They seek awareness of anything which can effect the function of their unit / facility.
Leaders are people persons. They believe in their staff. They encourage risk taking, acknowledging that growth often necessitates risk. They allow staff to make mistakes, and use those as opportunities for learning. They praise in public, and perform constructive criticism in private. They are aware of their staff in their professional roles, and also in their personal lives. They create opportunities for the staff to interact outside the workplace, knowing that team building is often accomplished through enhanced casual interactions.
The focus on staff retention is not solely a nursing issue. It pervades the facility. It is useful to discuss turnover issues and their resolutions within meetings of the facility leadership group. In these meetings, data gathering is important - to provide lessons which will avoid repetition of the problems. What works in nursing may not be appropriate for another area, and so the leadership group has the opportunity to develop a melange of resources, carefully chronicled for future reference.
In addition to the factors described above there exists a cluster of factors which have commonly been associated with improved employee morale. They include:
Shared governance: Encouraging staff to actively participate in running both their unit and the department of patient care. Staff need and deserve a place at the table where decisions are made. This initially may detract from productivity, but leads to rewards as staff view themselves as more involved in the working of the hospital.
Performance recognition: Recognizing staff who demonstrate excellence in patient care or other aspects of their responsibilities. This is not reserved for the annual evaluation, but occurs whenever there is behavior of merit.
A cafeteria array of benefits: Staff members have differing needs. Child care may be important to some, dental care or tuition assistance to others. Points can be allotted to each benefit, and the employee allowed to choose to a limit set by job title, performance, or tenure.
Support for attendance at professional meetings: As continuing education becomes a condition for continued licensure, this is highly regarded by professional staff.
Flexible work schedules: Early on in my leadership experience, I found that allowing staff to develop the work schedule together (as long as the requisite staff were present for patient care) went a good distance in developing camaraderie on the unit.
Celebrate nursing: Not just once a year in "nurse week" with ice cream and trinkets, but frequently - and for genuine reason staff develop a new clinical pathway which improves patient care; a staff member completes a degree or achieves specialty certification - any achievement which enhances the unit is worthy of public celebration. Be sure that the event is highlighted in the employee newsletter.
Finding a cadre of real leaders will not be an easy chore. Restructuring the facility, in physical plant, table of organization, operational procedures and employee benefits will take time, commitment and resources. The alternative is to continue the enactment of the legend of Sisyphus.
Roberta B. Abrams, a regular columnist for HealthLeaders.com, uses her education and experience to help further the evolution of healthcare delivery systems through her consulting group, RBA Consults, in Farmington Hills, Mich. She also is on the adjunct nursing faculty at Madonna University.