New to nursing leadership and having some difficulty

[nfdfiremedic, BSN, RN]

Hello all,

This will be my first post here on allnurses, though I have been a frequent reader for years. I'm hoping to reach out to the community for some advice dealing with issues in my current position. This is a bit of a long message, but I'm trying to clearly explain the situation and I want to give enough details and examples that everybody can clearly understand my predicament. Please forgive me for writing a novel here.

Three weeks ago today it was announced that I had been chosen as the new coordinator of the emergency department at my hospital. While I have no prior experience with nursing leadership, I am "battle tested" in this field. I was a paramedic for 7 years before becoming an RN, I am a certified emergency nurse (CEN) and I have spent the past few years building a strong reputation amongst/rapport with my peers in the ED. I have worked in this department for two years and, up until three weeks ago, I would have said that I had a very good relationship with every other staff member (from physicians to trauma surgeons to housekeepers.)

The hospital I work for is a major tertiary care center. We are a 32 bed ED and we see around 50,000 patients annually. We are a trauma center, a stroke center, a chest pain center, and pretty much every other kind of center there is. We are the "big hospital" to which every other hospital in this region of the state transfers their extremely sick of injured patients including the other trauma center 10 miles down the highway.

Despite our many accolades, we are not without our problems. The hospital we are attached to has a surprisingly small number of beds for such a massive facility, resulting in many admitted patients held over in our ED at any given time of the day or night on a daily basis (less than 10 is considered a good day for us.) This is extremely damaging to the staff's morale, since none of us signed up to be med/surg, tele, or ICU nurses. Our staffing is dismal. There was recently a "mass exodus" during which nearly a dozen veteran ED nurses took positions in other departments throughout the system. These spots have been filled, but most of our new hires are fresh out of school with little or no nursing experience. Add to this the fact that we are understaffed at least 75% of the time as a result of the "mass exodus" mentioned a moment ago, and you can imagine that we're in a difficult situation. Staff are reaching "burnout" very quickly, with some leaving the department within months because they are sick of dealing with high nurse/patient ratios (understandably.)

So, in the midst of all this chaos, I have emerged as the new department coordinator. When it was announced that I had been selected, I was extremely enthusiastic. I had big plans for making sweeping changes, improving morale, improving patient satisfaction scores, reducing left without being seen rates, and making the place better for everyone (patients and staff alike.)I have been assured by high level administration that the "wheels are turning" on the inpatient holdover issue, but these changes take time. There is talk of building a holding area or another inpatient floor but obviously these are not things that will happen overnight. Staffing has also been addressed. We have several travel nurses starting soon whom I hope will provide some immediate backup to the staff, as well as 4 new hires that will eventually be a significant help as well (I say "eventually" because they are mostly inexperienced nurses and will probably be on orientation for the full 6 months that we generally allow.)

In general, the staff have begun to treat me like the enemy. They no longer converse pleasantly with me like they had done throughout the past two years. They scatter when I approach them. They are very cold and very short with me. They look for any opportunity to complain about decisions I make, and they always seem to have excuses for not being able to do tasks I ask them to do. They complain to my operations manager about perceived wrongdoings on my part, i.e. "I asked for help and was told no help was available" when I myself spent at least an hour of my time at the bedside assisting the individual who sent the complaint since no other nurses could break free.

I have been pulled aside by two different friends in the department and told that emails I have sent are being re-mailed amongst the staff with various negative comments and nasty remarks attached. One particular email drew the ire of nearly the entire department, apparently. I sent out a message that I thought was a "rally the troops" pep talk email. I spent the first half saying how great a job everybody was doing and how positive the feedback has been from all the patients I have spoken to. At the end of the email I essentially said "You guys are doing a great job. As we move forward, here's a few things we should all try to keep in mind to raise the bar even higher and be the best we can be." I proceeded to mention a few things about being mindful of patient satisfaction issues, keeping the department tidy, etc. Apparently the first half of the message (the "you guys are doing great" part) was lost on all of them, and the message they took away from it was "You guys need to do all these things on top of what you're already doing." I've had people tell me that it was "condescending" and "the worst possible thing I could have said to a bunch of people that were iffy on me to begin with." Really? Condescending? I have reread that email a dozen times and I can't think of any way it could possibly have been perceived that way. The whole focus of the message was "You guys are doing a great job, let's focus on these areas and continue setting the standards high for the rest of the hospital."

I never experienced these problems when I functioned as the charge nurse, which I did very frequently with this same group of people. I have double and triple checked myself to make sure that the things I ask of them are realistic, and I genuinely believe they are. I know they are being worked extremely hard. I know they haven't got a lot of help because of our current staffing issues. I know they are trying to juggle inpatient caregiver duties and ED nurse duties since virtually every staff member has at least one or two holdover patients on top of some ED patients. At the same time, though, I know that I would never ask anything of any member of the staff that I myself would not be willing to do. Unfortunately we work in a very large, very busy hospital and there simply is no such thing as a "quiet day" here. I think that the environment here is so profoundly negative and morale is so very low that the group will tear down anybody who opens their mouth at this point, regardless of what he or she has to say. I'm just not sure what I should do to get through to these people. All I want to do is make things better for them, but they are fighting me every step of the way.

I registered on allnurses in the hopes that others who have walked this path before me can share some wisdom. I knew that accepting this role meant I would no longer be able to just be everybody's friend all the time since there would be difficult decisions to make sometimes. Several people warned me that becoming the leader of a group that already knew and established relationships with you as a peer would be difficult. The "right thing" isn't always the popular one. I never thought, though, that the entire staff would turn on me within a matter of a week when I haven't changed a bit. I still treat everyone with respect. I don't walk around like a big shot and act any different than I was before I got this job. I just do what I did when I was charge nurse before. I understand the need to 'choose my battles.' I don't go around giving people a hard time about every little thing (i.e. a drink at the nurses station.) What can I do to get this group to stop trying to scare me off and work WITH me instead of AGAINST me in order to benefit all involved?

[classicdame, MSN, EdD]

I di not read all of your long post, but I will say that knowledge and skills about a department does not always translate to leadership. You need to get some books, take classes (continuing nursing education), etc. to learn how to deal with conflicts, guide the staff into changes (new equipment, new people, new forms, etc) and other skills that are pertinent to being a leader. I think you have the right attitude or you would not have reached out to us. Let me recommend "Effective Leadership and Management in Nursing" by Sullivan and Decker. Not a big book, but has big ideas.

[noahsmama]

First let me say that it's great that you're enthusiastic and want to improve your department. HOWEVER.....

You're chronically understaffed, have had a mass exodus of experienced staff, are fighting physical limitations of your facility that aren't going to be fixed any time soon, and you sent them a "rally the troops" email in which you talk about improving patient satisfaction scores and keeping the department tidy?

They're not your "troops", and who says they need rallying? If I was working my butt off in those conditions, I wouldn't appreciate an email from our new coordinator that didn't address (as far as I can tell from your description) any of the core issues that are making my job hard, but which instead said, effectively "You're doing a great job, now here's a list of ways in which I want you to work even harder".

I'm sure you didn't mean it that way, but I can totally understand why the staff is upset. They probably feel like they're already working as hard as they can, and that they're not going to be able to devote any time or energy to things like improving patient satisfaction scores or keeping the department tidy until more fundamental issues like understaffing are addressed.

I realize you're in a difficult position because there are severe limits on the extent to which you can address these core issues. However, I think you need to understand that until and unless these issues are addressed, you will continue to lose staff, and that sending them emails trying to "motivate" them to work even harder are sure to backfire, no matter how much you preface them with glowing descriptions of what a great job they're doing already. If you can't change the big issues that are making their job harder, try to identify little ways in which you can make their job easier, and that might help improve the morale problem at least a little.

I hope this doesn't sound unsympathetic -- I understand that you're caught between a rock and a hard place, but unfortunately, I think that tends to be the nature of having a management position -- which goes a long way in explaining why I don't think I ever want to have a management position!

I am offering this perspective in the hope that it will be helpful -- best of luck to you!

[nfdfiremedic, BSN, RN]

Thanks for your feedback. The email I sent did include mention of the two big problems (physical limitations and staffing) and also talked about what is in the works for both. I told them about the extensive meetings that I have had with upper level administration regarding the holding problem, and that the "wheels are turning." I also gave them a detailed explanation of the new staff we have coming into the department. We have a total of three travelers, four new hires, and two formerly per-diems turned full timers.

I recognize that this is a group that has really been "beaten down" over the past 6+ months and has been working extremely hard. The overall tone of the message was 'the calvalry is coming, things are going to get better very soon.'

In light of your comments, I can see how this message may not have been appropriate to mix with 'and here's some stuff we can do better.' I guess my problem is I'm so eager to "jump right in" I'm trying to take on every issue at once rather than one at a time. I know that past leaders in the department have been quickly washed out for "underperforming" and the only criteria upon which they were judged were things like patient satisfaction scores, left without being seen rates, handwashing rates as determined by amount of soap used in the department, etc. I'm just trying not to get "benched" in the first inning for turning in crappy numbers at the end of the quarter. I honestly think I can make a difference here and make this a great place to be a nurse given the chance.

[elkpark]

I don't have any helpful advice, but just wanted to point out that it's notoriously difficult to move into a leadership role in the setting in which you've been working for quite a while. People tend to resent (or just have difficulty taking seriously) someone who has been a peer all this time and is now suddenly "the boss." Many organizations promote people into leadership positions in units/departments other than the one in which they been working, but that isn't always practical (like, if the reason you're being promoted is because of your specific clinical experience).

Best wishes for a difficult situation!

[Esme12, ASN, BSN, RN]

I see that you are from the Northeast....so am I.......are you at a collective bargaining facility or non collective bargaining........It makes a difference as I have managed both. The thing is now they have seen many managers try to come in on pretty white horses and shining armour only to be swallowed up by the sucking void known as administration and they have either been betrayed or abandoned. YOu are now no longer an "US" but a "THEM".......give them time.

[canoehead, BSN, RN]

Can you bundle all the admitted patients into one area and call it observation? then send one or two nurses to take care of the admitted patients, call it a break. Give them a chance to fluff and puff for a shift. Or if people don't want to work there let them know everyone will take turns and it will minimize the hassles of dealing with admitted and ER patients at the same time.

Make sure they have all the personal care niceties you can afford for the patients, enough thermometers, warm blankets, etc. If there have been shortages that's an easy way to impress your staff. Encourage the staff to call social work, chaplains, PT, RT to take off some of the stress. Hire an extra aid or secretary. Don't question OT because breaks were missed.

[Freedom42]

I agree with the above posters: You now wear the cloak of management. For many of your co-workers, it no longer matters how experienced, how smart, or how trustworthy you were when you worked alongside them. You're now one of "Them." If you have the authority to hire and fire, you're suspect. If you don't, you certainly have considerable say, and there are immature people in your ranks who will resent you no matter what you do or how graciously you do it. Sad, but true. (I work for a new boss who is reviled by many even as she has increased the size of the staff and increased training opportunities. She's got some nerve, hasn't she?)

Hang in there. Your posts suggest you have the best possible intentions. You've simply got to persevere. Your own great performance is the best way to win over naysayers.

[netglow, ASN, RN]

Yeah about the "us and them" thing. Also, remember nurses are well, "nurses" they pile on like a bunch of fire ants "just because". So, there's that. Thing is, and this is good advice given here to new grads who feel they are being driven out of their job by bully nurses (well it's true they are being bullied) but, the sage advice is to just keep showing up. This is true for you as well. Another thing. People who have never been in business see staff email as punishment, and it doesn't matter what the content is. Just the fact that they got an email from you means for some reason you are "lording" over them. IDK why, but it is a trait I see as well in nursing staff. Heck, OP send me email, I won't get all shook about it (I'll delete it) --just kidding. Admin knows you are catching flack, so do they, nothing new. But here's the deal, you have to now build other alliances. No longer should you get caught up in staff riff-raff, see how silly that would be? You aren't them anymore Management should keep an ear open, but always remember that since you were one of the troops, they feel that they can still bully you and get a rise out of you just as they do to each other. They are treating you like "just another staff member" because that is their way of stripping you of your promotion, ya see Keep on working tirelessly on your overall larger goals. Keep at the upper admin for every last detail of what you envision as "the squeaky wheel gets greased first". Build relationships with new people, those people you need to assist in getting your work plan done. DO MANAGEMENT THINGS!!!! Remember, staff comes and goes, you must concentrate on you and your career, and to be happy you need to see your plans happen. Get to work on that!

[nfdfiremedic, BSN, RN]

Thanks again for the continued responses.

My hospital is a collective bargaining facility. I'm not sure the extent to which this is contributing to the hardship. Staff do file frequent grievances due to staffing levels (I see them filling out the papers sometimes) but honestly, I've yet to hear a word about any of this through official channels. I'm not sure if the union is stockpiling them in an attempt to surprise me with a large number of complaints (as if I didn't know there was a problem) or just slow to act. Either way, it's certainly not as though the problem hasn't been addressed. Like I said, there are 3 travelers starting, 4 new hires, and two per-diem staff converting to full time so there is definitely progress on this front.

Consolidating admitted patients has met with mixed results. Some staff request that I give them all admitted patients once they have been assigned a few to avoid having to provide both ED and inpatient care at the same time. Others abhor the thought of caring for admitted patients, and are appalled at the thought of doing nothing but inpatient care for an entire shift. I have tried it from time to time, and my success with this tends to be entirely dependent upon which staff are on duty. I realize it's not always possible to please everyone. My goal is really to provide a safe environment more so than anything else.

And thanks to those who stated that my intentions seem to be good. Indeed, they are. I want this to be the sort of place that people say they are happy to work in. Right now very few staff members in the department would say they are happy. Even the ones who like the job are stretched awfully thin and would probably tell you it's getting harder and harder for them to say they enjoy what they do. I'd like to make this into a place that people are hoping to "get into" because it's such a great place to work. Happy staff leads to happy patients, which leads to better reputation for our facility amongst the public and further contributes to staff satisfaction.

[CompleteUnknown]

Hi ntdfiremedic, I feel for you! I've been in a similar situation a couple of times over the years (although not in the ED) and it's much much harder than you think it's going to be when you take it on. I also found that change and improvement takes a lot longer than you'd ever believe.

If you were generally liked by the rest of the staff before you took this on, and they felt you knew what you were doing and understood the issues, it may be even harder for you because it's possible that the rest of the staff are believing that you should have been able to fix many of the problems almost straight away. They may be very disappointed and thinking 'hah there you go, she/he is just like all the rest, all talk and no action'.

I think I'd tone down the 'you're doing great, but do better' emails too. I know that's not how you meant it but it sounds like that's how it was taken. I've felt the same about memos and emails from various bosses over the years, it can feel like a slap in the face.

I'd say try to find something small to focus on to begin with. You can't change the staffing or the problem with the lack of beds and who knows how long that's going to take, despite what you've been told. It could be years, it could be never, and the staff have probably heard it all before.

Is there anything small but reasonably easily 'fixable' that is really annoying the staff? You used to be one of them, you probably can think of a few things. Take a little time to tread water, keep things going as they were and make sure nothing is actually going backwards before you start trying to implement anything new. I know you want to get in there and make a difference straight away but honestly, that usually doesn't work and you run the risk of failing. Start with one or two small things at a time and then leave it for a while. See what happens. If it works, start on the next thing. If it doesn't work, be prepared to tell your staff 'well that didn't work, let's think again'. Listen to the staff, they may have ideas that you haven't thought of. I'm sure you know all this, you just need to make sure that the staff can see that you know it.

Find something to praise in the staff as often as you can. Not in an over the top way, just a quiet 'thank heavens you caught that, well done' or even 'wow, this has a been a bad day, thanks for staying the distance'.

The staff probably haven't really turned on you (unless you're an absolute horror lol), it's just that now you're the boss. They're probably worried that an offhand comment or a whinge or a complaint while you're in earshot may be taken the wrong way.

Feel free to disregard all of this if it's no help, I don't mean to be insulting or give the impression that you don't know what you're doing. I also realise that you're getting pressure from above and are worried about being seen as underperforming. It's a difficult position to be in, I wish you the best of luck.

[llg, PhD, RN]

Welcome to leadership. Now perhaps you can read all those other threads complaining about "managers" with an eye more sympathetic to the manager.

From a practical standpoint: You have to realize that the staff are no longer your "peers" as they don't understand your job. You can't expect them to understand your job, your problems, your point of view. It would be nice if they did -- and maybe they will some day. But that's not going to happen right now. You need to get your support and guidance from your boss and from your new peers, your fellow managers.

I suggest you put out a call for "Help!" to your boss and to the managers in other departments of your hospital. You may be thinking, "But they don't know the ED. ED is different. How can THEY help me?" Every unit thinks that, but in fact, the clinical specialty of the unit is less important than the basic human dynamics of leadership. Develop relationships among the other nurse managers. Find mentors and supportive friends among that group. They can help you in practical ways -- and also emotionally.

Also ... do you have a leadership team in the ED? By that, I mean educators, a medical director, an assistant manager, etc. Building a team of leaders around you can help provide support for you as you make changes as a team and support each other. You might also want to explore getting a group of staff leaders (e.g. charge nurses, preceptors, etc.) together periodically to share responsibility for positive change in the unit. Work groups, teams, etc. can support each other (and you) and move individual initiatives forward.