Nursing Management Getting Down & Dirty On The Floors

elkpark · Mar 16, 2010

When I started out, the NMs and other nursing management people were the clinical experts, the people you called when you couldn't get the IV in, or had some other kind of clinical problem. In the hospital in which I trained (diploma program) and had my first job out of school, the DON came to work every day in her starched white uniform, white hose and cap, and had better clinical skills than any other nurse in the building -- she was the "go to" person when you were really stuck, and she would come help out on the floor (as would any of the NMs) when things got really hectic and crazy.

I miss that system -- I've known too many NMs and DONs since then that I wouldn't let look after my dog, let alone care for a sick client ... :)

Moogie · Mar 16, 2010

When I worked acute care in the early to mid 1980s, I never, EVER saw a nurse manager (aka "head nurse") take patients. Never. Not once. Not when we were so understaffed past the point of being ridiculous. One weekend we were incredibly understaffed with two RNs and two CNAs to take care of twenty-two patients. Day shift. Worked out to eleven patients for one RN and one CNA. The "head nurse", who didn't know her backside from a bedpan, worked "charge" that day and sat at the desk while the rest of us busted our butts trying to deliver adequate care. She used to pride herself on running a tight ship and how she always kept her floor under budget because we were chronically understaffed. But she never, EVER lifted so much as a finger to do one bit of direct patient care.

I transferred off that floor and eventually worked on two different floors in which the staffing was better but again, the "head nurse" always worked charge and never took patients.

A friend of mine from nursing school ended up becoming a nurse manager and was extremely successful and well-respected by administration, staff, and patients, in part, because he regularly took patients and knew what was going on in the trenches. He also made sure his floor was well-staffed and he never asked anyone to do something he would not do himself. :up:

When I was a clinical instructor at a different hospital years later, I rarely saw the nurse manager venture out of her office. Never saw her on the floors. Never saw her within shouting distance of a patient room. Staff was burned out and dissatisfied. I am not sure the nurse manager ever noticed.

Similar scenario in LTC. Nurse manager rarely poked her head out from behind her clipboard. She did not help on the floor although, because she valued answering call lights, she would occasionally answer a light if she happened to be around. I don't know how helpful that was or if it was meant mostly for show because if she did answer a call light, she would go off on the staff members who weren't there to answer it quickly enough.

I think it is wrong for administration to consistently expect nurse managers to fill in whenever a floor or facility are short-staffed, mostly because nurse managers are salaried rather than paid by the hour and they need time to get their work done, too. It is wrong for administration to expect them to put in more than 40-hour workweeks when they are not eligible for overtime. However, I think it is imperative for anyone in management, even the CNO, DON, or DNS to occasionally work the floor, not only so they can keep up their clinical skills but also so they can understand and appreciate what their staffs do.

elkpark · Mar 16, 2010

When I worked acute care in the early to mid 1980s, I never, EVER saw a nurse manager (aka "head nurse") take patients. Never. Not once. Not when we were so understaffed past the point of being ridiculous. One weekend we were incredibly understaffed with two RNs and two CNAs to take care of twenty-two patients. Day shift. Worked out to eleven patients for one RN and one CNA. The "head nurse", who didn't know her backside from a bedpan, worked "charge" that day and sat at the desk while the rest of us busted our butts trying to deliver adequate care. She used to pride herself on running a tight ship and how she always kept her floor under budget because we were chronically understaffed. But she never, EVER lifted so much as a finger to do one bit of direct patient care.
I transferred off that floor and eventually worked on two different floors in which the staffing was better but again, the "head nurse" always worked charge and never took patients.
A friend of mine from nursing school ended up becoming a nurse manager and was extremely successful and well-respected by administration, staff, and patients, in part, because he regularly took patients and knew what was going on in the trenches. He also made sure his floor was well-staffed and he never asked anyone to do something he would not do himself.
When I was a clinical instructor at a different hospital years later, I rarely saw the nurse manager venture out of her office. Never saw her on the floors. Never saw her within shouting distance of a patient room. Staff was burned out and dissatisfied. I am not sure the nurse manager ever noticed.
Similar scenario in LTC. Nurse manager rarely poked her head out from behind her clipboard. She did not help on the floor although, because she valued answering call lights, she would occasionally answer a light if she happened to be around. I don't know how helpful that was or if it was meant mostly for show because if she did answer a call light, she would go off on the staff members who weren't there to answer it quickly enough.
I think it is wrong for administration to consistently expect nurse managers to fill in whenever a floor or facility are short-staffed, mostly because nurse managers are salaried rather than paid by the hour and they need time to get their work done, too. It is wrong for administration to expect them to put in more than 40-hour workweeks when they are not eligible for overtime. However, I think it is imperative for anyone in management, even the CNO, DON, or DNS to occasionally work the floor, not only so they can keep up their clinical skills but also so they can understand and appreciate what their staffs do.

Interesting -- it was in the mid-'80s that I had the experience I described above ... Our NMs did not routinely take a patient care assignment, but they were sure there (in uniform, as I said, up to and including the DON) to be an extra pair of hands or bail us out when things were extra hectic or there was an extra-tough clinical situation.

Moogie · Mar 16, 2010

When I started out, the NMs and other nursing management people were the clinical experts, the people you called when you couldn't get the IV in, or had some other kind of clinical problem. In the hospital in which I trained (diploma program) and had my first job out of school, the DON came to work every day in her starched white uniform, white hose and cap, and had better clinical skills than any other nurse in the building -- she was the "go to" person when you were really stuck, and she would come help out on the floor (as would any of the NMs) when things got really hectic and crazy.
I miss that system -- I've known too many NMs and DONs since then that I wouldn't let look after my dog, let alone care for a sick client ... :)

I have never had that experience, even though I started my career as an RN in 1980. I do remember a couple of head nurses who were expert clinicians but I rarely saw anyone in management ever act as the "go to" person in a clinical situation. The exceptions, however, were the house supervisors who worked evenings or nocs. They had excellent skills, were recognized as clinical experts, and would be available if a nurse or a floor needed help.

One downside, though, about having expert nurses serve in management roles is that, although they may be clinically proficient, they don't always have management skills. But now I think the pendulum has swung too far and it would be better if nurse managers had clinical skills in addition to management skills.

Moogie · Mar 16, 2010

Interesting -- it was in the mid-'80s that I had the experience I described above ... Our NMs did not routinely take a patient care assignment, but they were sure there (in uniform, as I said, up to and including the DON) to be an extra pair of hands or bail us out when things were extra hectic or there was an extra-tough clinical situation.

In all honesty, I am envious that you had such good role models. I think you and your colleagues---and especially your patients---were fortunate indeed!

elkpark · Mar 16, 2010

Oddly enough, as I recall, they were all at least decent managers, too. It was a old, established hospital that prided itself on the excellence of the nursing care it provided (and the excellence of its nursing school and its graduates) and put time and energy into cultivating and developing the best nurses into first-rate managers and administrators. All the energy and efforts of the nursing administration were focused on ensuring that clients got the best care possible; the standards were incredibly high, and I continue to be grateful that I got such an excellent nursing education and exposure to such good role models. I've been disappointed by most of the facilities and nursing administrators I've encountered since.

I agree that it seems reasonable to expect some "happy medium" between clinical skills and managerial skills in a NM.

tewdles, RN · Mar 16, 2010

hhhmmm...

I was one of those NMs in the 80s and 90s. I did not wear starched whites cuz we were in a PICU, but I was one of the go to people. I frequently relieved nurses for breaks in the sickest rooms, watched kids in the unit so that the unit nurse could respond to the pedi call in the ER (although going to the ER was much more fun!). I did admissions while we waited for the per diem nurse to arrive...etc.

My job was to manage the department and the professional nursing staff. I was available 24/7 which was not that much fun, but the staff didn't abuse me...just like I didn't abuse them. We were a team and I was the team facilitator. There were leaders within the staff whom I nurtured, they were often in charge on their shifts and had the respect of the staff...one of them replaced me when I left.

In the early 80s, before the HiB vaccine, we would burst at the seams in the winter months...too much morbidity and mortality from that bug. Our 12 bed PICU would expand to 20 or more as we would encroach on the adjacent adolescent/trauma unit and mandatory overtime became the norm for weeks. My name went on the schedule for OT just like everyone else. I was, after-all, a capable and experienced PICU and transport nurse. I could see no good reason why I should get to go home after my 7-5 shift when nobody else had the same luxury. Of course, I was the cheap labor in those times...being salaried and all.

There were management "things" which surely suffered during those times. However, the director of maternal child services for the hospital was well informed about the situations and she picked up some of my responsibilities while I assisted the direct care staff. We got things done and we had a happy staff and a happy administration (pretty sure). Heck, I would ask the director to come to the unit to babysit for breaks during the winter season...she was after-all a NICU/PICU trained RN.

I find that nursing management is just like other nursing...it becomes more and more about the paper with less and less time for the person. The good nurses and the good nurse managers realize that they must prioritize differently if they want to be successful. Sure, you have to get the paperwork done, but it is only intermittently a priority...the people need to come first the vast majority of the time.

snoopy29 · Mar 16, 2010

Sounds like we are still quite lucky here in the UK - but to be fair a lot of the push is motivated by the fact we are measured so carefully on government set targets, and financially penalised if we fail!

Take last night, the hospital was full to the rafters and the only space available was potentially from a few outliers (patients waiting for discharge who could be moved from acute bed space). When I came on ambulances were queueing out of the door and the department had over double the usual amount of patients in it, many very sick.

Our backs were truly against the wall but the senior nursing team on for the hospital who had worked all day put scrubs on and mucked in with my nurses. By their own admission they say their clinical skills are a bit rusty but in order to get the job done then they are more than happy to role their sleeves up. Last night this included the senior nurse for the hospital rolling her sleeves up and washing and toileting patients. Makes my nurses more willing when they know the powers that be are prepared to help. Knowing that we would not get breaks one of the bed managers went and got cold drinks and snacks out of their own pocket.

I think it makes a massive difference if managers are prepared to lead from the top. Interestingly from my personal experience the upper management nurses are more than happy to muck in, it's the middle management nurses that are conspicuous in there absence. Many a Christmas or public holiday or busy weekend has passed with no-one from the next teir popping there head in to encourage the ranks and show some solidarity and support :)

llg, PhD, RN · Mar 16, 2010

While I don't disagree with the general sentiments being expressed in this thread ... we have to be fair and acknowledge that the jobs of the Nurse Managers and DONs have become much more complicated and stressful in recent years. It's not just the role of Staff Nurse that has gotten more complex and stressful.

Those "old time" nurse managers worked under far different conditions than those of the nurse managers today.

onetiredmomma · Mar 16, 2010

The last and current managers I have worked for have both been available to help us on the floor. The previous NM would work as a staff member (not charge) on weekends when we were short. Our current manager while not takig an assignment will start IVs, do admission history, cover while we go to lunch, answer call lights....IF she isn't being meetinged to death! I originally went to school and got my LPN cause I didn't want to be a "desk nurse" (my term) which is what I saw RN charge nurses doing back in the 70s.

Rabid Response · Mar 16, 2010

Nurse managers rarely help out on the unit in my hospital and would not take patients unless the building was falling down around us. However, this is not their fault. Our contract stipulates that every single available nurse must be called in (and offered overtime) before a manager can even give a BREAK to one of our nurses. I guess I see the reasoning behind this, but it makes life hard when we are understaffed and get three admits to the ICU at 0300. I have known nurses to actually file complaints against managers for helping too much with bedside care. There is so much friction between management and staff nurses in the critical care areas of my hospital that I think it interferes with patient care at times. Not surprisingly, we go through managers like crazy; it is truly a thankless position at my hospital.