Chapter 1
Laying the Groundwork   

5West is a general medical/surgical unit in a community hospital in Illinois. The hospital has been in a state of flux for several years, and it has closed several units in order to consolidate staff and lower costs. As a result of these unit closures, some staff members were moved to 5West two years ago. The dissent among the staff is still high, and the morale low, and the manager became discouraged and recently left in disgust.

Why is it important for bedside nurses to understand the basics of management? The tumultuous story of 5West calls for not just clinical skills, but also management judgment. Both perspectives are vital in communicating with and coordinating professional and support staff, and in guiding patients and their families. While nurses are trained to be clinicians, nearly all nurses will find that they have management responsibilities once they enter into full-time nursing practice.

It is essential for nurses to become familiar with and proficient in management skills, such as understanding the mission, vision, values and culture of their organization and their units. They will also need well-honed people skills such as coaching and supervising fellow staff members, delegating, evaluating outcomes, and understanding the costs of patient care.

Today’s health care system creates pressures on provider organizations to reduce costs, limit lengths of stay and economize on staff and support services. As most nurses know, these pressures directly affect the everyday activities on the units in organizations across the country. Nurses are in key positions of influence, not only on patient care outcomes, but also on the effectiveness of the organizations in which they work.

Still more factors underscore the importance of management skills for nurses. Chief among these is today’s serious nursing shortage. Indeed, the health care system is faced with the third nursing shortage since the 1970s. In the earlier shortages, with a concerted effort, the system generated many new nursing students, and within two years, the shortages were resolved.

This shortage is different, however. Career opportunities for women are significantly greater. Many women who might have chosen nursing as a career now select medicine, law, computer science, or corporate management, to name a few of today’s choices for women.

The nursing shortage is “evidenced by fewer nurses entering the workforce; acute nursing shortages in certain geographic areas; and a shortage of nurses adequately prepared to meet certain areas of patient need in a changing health care environment,” according to the Tri-Council, which is comprised of the American Association of the Colleges of Nursing, the American Nurses Association, the American Organization of Nurse Executives and the National League for Nursing.¹ Adding to the problem is the fact that the present average age of employed RNs is 43.3 years, and RNs who are under 30 make up only 10% of the working nurse population.²

These demographic pressures are likely to continue or accelerate. The impact on nurses at all levels must be understood, acknowledged and accommodated if nurses are to remain competent in their work and satisfied in their professional lives. Enter the importance of management skills: Many staff nurses will not only be providing bedside care to more patients, but they will also be in positions of responsibility for other nurses. They may be charge nurses on a given shift, team leaders, permanent charge nurses or nursing supervisors and managers. Even newly trained staff nurses will need to assume some management tasks. Thus, for the sake of the professional satisfaction of every nurse and to promote the highest quality of care for patients, it is vital that nurses be prepared to not just care for, but also manage their colleagues and peers, their patients and their families, and themselves.

In this first chapter, we will review the patient unit environment and the importance of the mission, vision, and values of the health care organization. We will identify key aspects of workplace culture and how they influence what nurses do—as caregivers and as managers. 

Patient unit environment

In an effort to reduce costs, the vice president for patient services has just asked the experienced manager from a neighboring unit to take over 5West. The manager was selected because she values sound clinical practice and cohesive teamwork. She reflects a concern for staff that can help to stabilize the unit.

The manager’s first action is to ask the 5West staff to identify three shift charge nurses who can help with teaching and coaching on the unit to help with patient care and to stabilize the environment.

She appoints a committee from a group of unit staff volunteers to develop the criteria for selecting the charge nurses. She reviews the vision and values of the organization so that the committee’s criteria can match the priorities and values of the larger organization. The committee members also have the opportunity to describe the vision and the values of their special unit and incorporate them into the criteria.

The selection was made in two weeks, and staff loyalties and teamwork began to develop.

Vision, mission, values, goals

The values of an organization are a reflection of the values of the board of directors and the community leadership. The board and senior management team may identify values in the strategic planning process.  Those values are then reflected in a thoughtfully developed vision statement and a more specifically defined mission statement.

These statements are important because they help guide organizational decision making. Additionally, people often join the staff of an organization because their own values and vision fit with those of the organization. For example, in academic medical centers, organizational values often include education of providers and research for better patient care.

An organization’s vision for the future will be based on these values, as will the statement of the mission. For example, some academic centers focus their mission on preparing providers for the state in which they are located. Others focus on preparing the researchers and the future teachers of clinicians in a broad region or across the nation.

Community hospitals, on the other hand, provide care for patients as their primary mission. All community hospitals are concerned with the economic viability of their institution. The hospital must be financially sound in order to serve its community.

Each year the hospital’s leadership team develops short-term and long-range goals, which flow from the vision and mission. The goals are more specific and have the characteristics of being measurable, attainable, relevant and timely. Senior management will ask department and unit managers to develop such goals for their areas of responsibility. These should flow from and be consistent with the goals of the hospital or health care agency. Monthly or quarterly leadership teams evaluate progress toward attaining the goal.

At the unit level, the patient care manager will be setting goals for the year. A manager who is oriented toward a participative culture will involve the staff in as much of the goal development as possible.

A hospital that values the participative process will require the manager to involve the staff in setting goals and may provide the coaching for the manager to accomplish it.

Because the experienced manager promotes a participative culture, she involves the staff in unit goal development for 5W. This action is consistent with her earlier action of asking the staff to participate in the process of selecting the charge nurse.

The table shows the correlation between the values, vision, mission and goals of the community hospital as a whole and those of the 5W unit. This is just one example of specific goals for a given hospital and unit. Other community health care delivery settings, academic medical centers, and other provider organizations will have different values, vision, mission and goal statements.

Culture

The three charge nurses who were selected developed very different cultures for their shifts. One charge nurse, Joan, had most of her experience in a very authoritarian environment. She used her former charge nurses and managers as role models on how to get things done. The staff soon came to resent her. Joan seemed unwilling or unable to work through staff conflicts with coaching techniques, and several staff members decided to leave.

The second charge nurse, Janine, had a very different style, and the staff loved her. Soon, however, they began bickering among themselves about the schedule and about who had more work to do. Because they didn’t want to disappoint Janine, they didn’t share their concerns with her, and she let them do as they pleased. Many became frustrated, and several of them decided to leave the unit.

As staff members began to accept different jobs, the manager worked with Janine to help her coach her staff. She stressed the need to understand the parameters of policy and safety in a self-scheduling approach. She helped them develop effective criteria for a safe, efficient, and clinically sound schedule.

The bickering stopped as the staff began to take responsibility for the schedule and negotiate with each other in a positive fashion. Janine reminded them of the criteria whenever they hit stumbling blocks. Some staff returned to the unit, and the environment once again became one of teamwork. The staff began to take on other aspects of shared governance, and they continued to be open to coaching from Janine. She was able to help them understand the boundaries within which they could govern. The culture was developing into a positive and participative shift.

The third charge nurse, Susan, was coming to the role with previous experience on 5West. She enjoyed the role of charge nurse whenever her manager assigned her to the job on a shift-by-shift basis. She wanted to hone her leadership skills and knew that the new manager would work with her to develop those talents. Her first assignment as permanent charge was to get to know each staff member better and to assess and appreciate his or her skills. She did this by working closely with each nurse in patient care.  She also negotiated with them on their preferences for scheduled times and for clinical practice.

She discovered that each had individual personal needs such as family responsibilities and other concerns. Also, each of her staff members was in a different place in his or her clinical development. With the support of the manager, Susan coached each nurse in areas that benefited from further development. She also used shared clinical experiences to enhance critical thinking skills. The evening shift soon earned the reputation as the exemplary unit in the hospital. Call-ins were few and far between, and the staff helped each other out when family responsibilities surfaced.

According to Judd Allen, PhD, president of the Human Resources Institute in Burlington, Vt., “Whenever two or more people come together with a shared purpose, they form a culture with its own written and unwritten rules for behavior. Our families, workplaces and communities all have culture. These cultures have a tremendous, though rarely recognized, impact upon our behavior as individuals.”²

In society at large, culture is an accumulation of factors in our environment—these may derive from religious, social, political, economic, family of origin, ethnic identity or other factors. In workplaces, such culture is often referred to as “corporate culture.” In health care, this culture is sometimes referred to as “the environment of care.” Here, its elements may include those already mentioned, and also professionalism, peer support and expectations, and institutional norms and conditions that have been established through many years of providing care. Together, these threads of culture form a context in which nursing care is provided and health care services are offered on a given unit, a particular floor, in a specific institutional setting. Every nurse operates within a corporate culture, or environment of care, with its unique brand of expectations and norms. Every nurse also operates within a unit culture, as the continuing story of 5W above illustrates.

The environment of care influences how nurses relate to one another and how they relate to other nurses when they are in leadership roles. If the environment is authoritarian and hierarchical, that culture may create expectations that nurses who are new to their managerial roles behave in authoritarian, dominating ways.

It is important — especially for nurses new to management — to realize that unit culture is not just a “fact of life.” Nurses can influence the culture and environment of the nurses and patients they serve. They can set an example, such as being flexible in their leadership style. For example, sometimes it is appropriate to be decisive, without spending much time conferring, such as during emergencies. At other times, a nurse can focus on developing others. Taking a coach-like approach, the nurse will respect the professionalism of others. The nurse will take time to listen to and train colleagues and will invite them to coach and train him or her. Such actions invite shared governance, pooled knowledge, increasing skill, mutual support, and clinical excellence.

At the unit level

The culture at the unit level is not only a function of the organization’s culture but is also a result of the collection of individual leaders and staff on the unit. The story of the three charge nurses, Susan, Joan and Janine, illustrates the enormous impact each has on the culture of her shift. Indeed, each unit has its own personality, as does each shift. The culture is derived from the values of the group as a whole.

5West has a collective spirit that has at its core the following values:

• Clinical competence
• Smooth teamwork and collaboration
• Patient-centered decision making
• Respect for staff members and their family needs

The values of 5W are role-modeled by the unit manager and reflected by the behavior and decisions of the unit’s shift charge nurses. The following story of Mr. Hagen illustrates the significance of culture and its impact on patient care.

Mr. Hagen has just been admitted to 5W for the third time in three months. He was admitted for an increase in shortness of breath as well as an increase in pain resulting from mets to the bone. In addition to his oncologist, a surgeon, a pulmonary specialist, and an anesthesiologist who specializes in pain management are following Mr. Hagen. The coordination of the assessment, orders, and plans from all these physicians challenges Mr. Hagen’s nurse, Clare. This requires that she remain in close communication with the oncologist, who is the physician of record (admitting physician), to ensure collaboration.

When the report was called from the ER, Clare inquired about the level of Mr. Hagen’s pain and his shortness of breath. The ER nurse alerted her that he was acutely short of breath and that he assesses his pain level at a level 6 of 10. She requests respiratory therapy and pain medication orders from the oncologist immediately. She will have the RT on the unit set up O2 and can ask the pharmacy for a stat analgesic delivery. His pain medication arrived within 15 minutes of Mr. Hagen’s entrance to the unit. Clare reviews his ER chart for the latest dose and is able to administer some relief for her patient immediately.  The patient’s wife is present. She gives Clare an accurate history of the management of his pain and shortness of breath at home before admission. Mr. Hagen is able to confirm the history.

Because Mr. Hagen had been a patient on 5W before, the day shift staff had become aware of his diagnosis and prognosis and wanted Clare to continue his care for continuity’s sake. Clare’s charge nurse, Susan, negotiated with another staff RN to support Clare with her already full load of patients.

This segment of the story demonstrates the culture of 5W and its direct impact on the patient’s care. Mr. Hagen’s anxiety about his pain and his SOB was immediately reduced because he was reassured by Claire’s clinical competence. Staff flexibility allowed them to support one another and Mr. Hagen’s continuing care. These actions flow from the values of the staff and the unit manager. The attentiveness of Clare to Mr. Hagen’s pain and need for immediate relief speaks to the unit’s focus on clinical competence.

At the end of the shift, Clare received a phone call indicating that her 7-year-old son, Peter, has a fever of 102F and is vomiting. She knew at that moment that she would not be able to meet her obligations for work the next evening. She worried that the plan for Mr. Hagen would get derailed. With the support of the charge nurse, she negotiated with Sheila, her RN colleague, to cover her shift the next two days in exchange for two shifts in the next week’s schedule.

During her shift report, Clare included Sheila in the report at Mr. Hagen’s bedside, reviewing the progress so far and the plan in the next days. Mr. Hagen had the opportunity to participate in the planning, and Clare had the chance to provide a smooth transition and continuity of concern through Sheila.

Such negotiating and concern for each other as staff results in exceptional teamwork and commitment to colleagues, to the unit and to patients. These all reflect the core values of the unit and the hospital as a whole.

In conclusion, nurses who are competent in their practice today will want to learn about and incorporate management perspectives and leadership knowledge in their skill set. They will be able to discern and articulate the mission, vision, values, and goals of their organization and the units in which they work. They will be attuned to the culture of that unit, and they will be aware of the important role they play in creating that culture. Most important, they will be able to see how an organization’s culture, and that of every unit, significantly affects the experience and quality of patient care throughout the entire organization.

Chapter 2
From Staff to Charge Nurse

Susan’s interview

Susan arrives for her interview with her colleagues on time, 1 PM, before the beginning of her shift on 5West. Susan has been an evening staff nurse on 5West for three years and has emerged as a leader and competent clinician. She has been asked to assume charge nurse duty several times when the regular charge nurse, Lisa, was off. While Susan has had no formal orientation to the role, she picked up some of the functions through the nurse manager and by watching Lisa move through her responsibilities. Lisa has accepted a promotion as manager on another unit, and the vacancy needs to be filled. Her nurse manager selects Susan and a competent nurse from another unit to interview for the promotion.

Susan is nervous. She is concerned how her colleagues will view her in the leadership role. She has had a very good working relationship with them all. She is worried about the distance that being an official charge nurse might bring to her relationships. Susan’s manager has reassured her that she will help her with the challenges of her new role. The skills she uses as a staff nurse will be very similar to the ones she uses as charge.

The interview committee members have been impressed with Susan’s clinical skills as well as her ability to keep smooth teamwork moving on the unit. They respect her leadership ability and appreciate her desire to pitch in when they get overwhelmed. They are confident in her ability to get the resources they need from other departments when they are busy taking care of patients. Susan meets the criteria the committee has designed. They value a BS degree in nursing, exceptional clinical competence, a calm demeanor in a crisis and talents in teaching and negotiation. Susan is chosen for the position.

Susan’s orientation

Fortunately, Susan has an opportunity to learn much more about the charge nurse role in a special orientation program for those newly promoted. This chapter is about what she learned and how her role will be similar but expanded.

Planning

Much to Susan’s surprise, the planning role is a major expansion of the planning she has already done as a staff nurse. When she comes on the unit, she makes an assessment of all of the patients, not just the group she might have taken care of as staff nurse. She must know the major aspects of each patient’s care. She gets this done through a report from the day shift charge nurse and from making her own rounds and talking with each patient. As she moves through the unit, she formulates a clear picture of the needs and develops ideas about how she can use the competencies of the staff most effectively. Susan is also in touch with the emergency room to assess the potential for any admissions that might be coming to 5West and discusses the generalized anticipated needs with the ER staff.

A great deal of planning depends on the model of professional practice the unit chooses to implement on 5West. Susan uses its framework to make assignments. The model of practice influences the number and mix of staff that have been scheduled. The data from an acuity classification system also provide information to insure the safe distribution of patient assignments.

She is aware of the clinical skills of each of the staff so that she can assign the appropriate nurse expertise to the right patients. She is also mindful of the needs of others of the staff who are looking to expand their expertise in specific areas and pairs staff together to accomplish this objective.

In addition to understanding the expertise of the RN staff, she is very aware of the kinds of support they get from the nurses assistants. She knows how well they work together and the limitations are of each nurses assistant, both physical and technical. She knows she must be careful of overtaxing those with any physical disabilities.

For example, one of the patients expected to return to the unit from the PACU is a 74-year-old who has just had a total hip replacement. The pain management protocol for hip replacements usually includes a patient-controlled analgesia IV pump. The procedures for calculating and setting the dosages for the pump require some extensive experience and validation with the PACU. Most of the staff are competent in the use of the pump and patient assessments. Still there are two RNs who are looking for experience to polish their skills. When making the assignment, Susan partners one of the less experienced staff with the most skillful RN in hip replacements to provide solid supervision and collaboration in the postoperative care of this patient. At the change of shift report, the day charge nurse validates the projected return time of the patient and reviews the anticipated needs with Susan. On her rounds, Susan talks with family members to assess their understanding of the anticipated care on the patient’s return. She is able to allay their fears about plans for the patient’s pain control.

Organizing

Because the assessment and planning process is so thorough and because Susan is experienced at it on smaller scale, the responsibility for organizing the care of all 21 patients as well as the new admissions seems less daunting. In making the assignments for efficient care she considers which nurse had specific patients the evening before and tries to provide continuity where possible. She also avoids spreading assignments across the unit so that nurses are not wasting time running from one end of the hall to the other. Specific models of practice frequently make the clustering of patients easier and less of a consideration in the assignment process.

As staff arrive on the unit and discuss patient care with the day shift, they will also be talking with Susan about the assignments. They offer constructive ideas for better clinical care. The staff might agree to rotate the responsibility for accepting admissions as  clinically appropriate to each nurse or team of nurses. If the staffing is tight, they may look to Susan to handle all new admissions as well as all new orders coming in. It is at the beginning of the shift that negotiations for changes or preferences in assignments take place in light of standards of the unit and projected needs of patients. Susan’s ability to negotiate has been sharpened during her years as a staff nurse. The negotiating process is an open and expected discussion so that that best ideas come forward. The charge nurse facilitates the negotiation while maintaining the standards of the unit for safe, effective patient care. The negotiating skills and the smooth teamwork make it possible for the staff to cover tight workloads efficiently and safely without sacrificing morale. The give and take of negotiation also set the stage for the staff’s ability to cover for each other in times of personal family crises. Susan is grateful for the groundwork laid by her predecessor and for the coaching the unit manager provides. The teamwork is effective.

The facilitation skills are new to Susan. Her unit manager is careful to integrate the skills needed in the leadership role into Susan’s orientation. Negotiating skills, management, flexibility, people development, teambuilding and decision making are all objectives of the orientation period. Susan’s critical thinking skills are well developed and very important to her success as a charge nurse.

Critical thinking

Critical thinking is a skill that is developed with practice in the patient care environment and covers a broader concept than decision making. Critical thinking is a reflective and creative thought process focused on discovering the root of a problem and its solution.¹ The process of evaluating the consequences of an action before using it to solve the problem is the primary part of the critical thinking process. The critical-thinking process is almost automatic for an expert nurse and is the core to a nurse’s expertise including the anticipatory planning.² The critical-thinking skills of an experienced staff in the negotiation process at the beginning of Susan’s shift provide an exceptional flow of work and thoughtful patient care. As facilitator, Susan has the job of critically evaluating the suggestions of the staff in light of her knowledge of the unit’s broader picture. As she shares her perception of the consequences of the staff’s suggestions and the ultimate plans for the shift, her modeling of critical-thinking skills is instructive to them. Her flexibility to do what is most important for patients and staff nurtures the staff’s respect for her leadership and their admiration for her participative style.

One of the cornerstones of the critical-thinking process is systems knowledge, whether it is the knowledge of the human body or the hospital organization as systems. Susan demonstrates her critical thinking skills from a clinical perspective based on her knowledge of the human body and the impact of illness. Her knowledge of the hospital as a system is more limited and takes coaching and experience from a unit manager to develop. She learns that the pharmacy’s ability to deliver needed medication in a timely manner is affected by its staff, its formulary and the current demands from other units including the ER and the operating room. Susan’s patience and her ability to articulate the urgent needs of patients are greatly improved. She is more likely to be taken care of by the pharmacy in order of priority than if she lets her impatience get in the way. She develops an awareness of the consequences of her chosen action within the systems environment. She is aware that unknown and unanticipated delays cannot always be predicted. Helping with the solution to reducing the delay is more effective than being critical of the pharmacist. She offers to go to the pharmacy to pick up the stat medications rather than waiting for delivery by a stressed pharmacy assistant.

As Susan’s systems knowledge becomes more developed, her ability to anticipate problems through systems thinking is related closely to her clinical critical-thinking skills. She develops the ability to anticipate delays or urgencies based on her knowledge of the events in the rest of the hospital. She enlists the evening supervisor in understanding the events and potential solutions as necessary. She supports her staff in their care of patients by taking thoughtful action based on her systems thinking skills.

For example, the ER calls to 5West urgently with a request to admit Mr. Hagen immediately because they are overcrowded. Susan is poised to help by providing the escort service for Mr. Hagen and taking this admission herself. Her own staff are working at maximum levels. She accepts report on Mr. Hagen from the ER staff and moves into action to provide the care that he and his family need. She calls to the respiratory therapy department and the pharmacy. At the end of the shift, Mr. Hagen is comfortable, antibiotics are running and O2 is in place. And Susan has succeeded in helping her colleagues in the ER with a crisis so that they can better care for those coming in the door.

Conflict management

The alternative scenario:

Mr. Hagen’s third admission: Mr. Hagen is a 53-year-old father of four who was diagnosed with lung cancer two months ago. Because of his severe shortness of breath, his family brought him into the emergency room on a Saturday evening about 8 PM. The emergency room is packed with emergencies as well as patients in temporary discomfort who could not see their own physicians. Because of the back-up, the wait is long, and Mr. Hagen’s shortness of breath becomes increasingly acute.

About 10 PM the registrar notices his distress as she is doing the paperwork for his insurance. He is moved into the ER on a cart and hooked up to nasal cannula with O2 by a passing nurse. She promises to be right back to collect more information and get the ER physician to see him.

Mr. Hagen’s cart is in the bay right next to the nurses station, and he is aware of angry voices. The ER charge nurse is arguing with the nurse up on 5North about admitting a patient who is awaiting a bed. The ER charge nurse insists she doesn’t care how many nurses called in sick. She needs to get this patient out of her emergency room! Voices are raised, and everyone is very angry. Mr. Hagen’s anxiety increases, as does his shortness of breath.

Twenty minutes later a nurse arrives in the ER, yelling at the charge nurse and jerking a gurney with the patient out of the ER saying, “I hope that staff doesn’t get to go home until 4 AM either”

Meantime Mrs. Hagen and her daughter are in the waiting room with no information about Mr. Hagen until 1 AM. Finally they take matters in their own hands and go in to find out what has happened. They find Mr. Hagen upset and even more short of breath. He has wet his gurney and patient gown because no one would bring him a urinal. The evening shift is gone, and the night shift was complaining non-stop about the two nurses who called in sick at the last minute. No one seems to know Mr. Hagen’s status, and the ER physician does not seem to have the time to speak with the Hagens. One of the nurses says she is waiting for his blood tests that she sent to the lab two hours ago to come back. Suddenly, someone comes in and takes Mr. Hagen away. Mrs. Hagen learns 15 minutes later that he has been taken for some chest films. Two hours later, Mr. Hagen returns.

The ER physician finally explains that they will admit Mr. Hagen to 5North because of complicating pneumonia. Mr. Hagen shudders with fear. He witnesses a repeat argument with the charge nurse on 5North about admitting another patient for whom they have no staff.

Finally at 5 AM Mr. Hagen is admitted to 5North, where no nurse sees him until the day shift arrives. When he is finally assessed and made comfortable, his nurse, Kate, discovers that he has an ER order for IV antibiotics that is to be started as soon as he is admitted. She calls the pharmacy to discover that no order was sent and that it will be another two hours before the antibiotics are ready. In her frustration, she yells at the pharmacist, who yells back. At 10 AM the antibiotics arrives. Kate starts the piggyback immediately and keeps a close eye on Mr. Hagen for increasing signs of distress and worsening pneumonia. She had her hands slapped last week for not ensuring that antibiotics were started within two hours of order, and that patient had not done well. She decides not to tell the charge nurse, because she knows she will be blamed for this delay as well. She had failed to report several other delays in the last six months for fear of losing her job.

This story must leave us asking, “Why is there so much conflict?” The immediate observation is that the system is stressed beyond its capacity, especially in the ER. But there are less obvious reasons that, with some anticipatory systems thinking and teamwork, can offer some solutions for handling such stress constructively.

“Conflict” is defined as an acknowledged struggle from differences in ideas, values or feelings resulting in increased stress levels between two groups or two people.¹ Both parties are aware of the conflict. It may be functional or dysfunctional. Functional conflict can be constructive in the problem-solving process when an open discussion of the problem surfaces and common goals are identified. Dysfunctional conflict continues to escalate stress levels and closes down communication, resulting in lose/lose results or a destructive win/lose mentality. The conflict in the emergency room is so dysfunctional that it seriously affected patient care. In addition, it spills over on the stressed environment on 5North.

Causes of conflict

Some of the most common causes of conflict include role definition, task interdependence and goal incompatibility.³ Certainly these causes were present in the ER the night Mr. Hagen was there. There is no one assigned to Mr. Hagen’s care, and his needs are basically unmet for most of his time there. There is a clear absence of teamwork between the ER and 5North. They are not only resisting any constructive interdependence but are at odds regarding their goals. The ER staff are frustrated because they need patients moved out of their unit while the 5North staff are angry over the fact that they have no one available to care for the patient the ER is transferring. Their goal is to stop any further admissions as they are at unsafe staffing levels. No one has the patient’s care as a primary goal. Everyone is primarily concerned about his or her workload. Hence a heated argument explodes.

Other causes for conflict in this scenario include group over-identification, win/lose attitudes and scarce resources. Both the ER staff and the 5 North staff are looking at each other wondering who is doing the most work: “They can’t be working as hard or be as stressed as we are….and I hope they don’t get to go home until 4 AM either.” Such an attitude develops into a we/they mentality in which someone has to lose. Of course, both units are without adequate resources to meet the consistently high level of stress with the steady influx of patients.

After several evenings of experience like this, the nurse managers and the evening shift charge nurses decide that something needs to be done. Their primary objective is to at least improve communication. They call a meeting of ER and inpatient charge nurses to discuss the problems and look for some solutions. They validate that the goals were not the same and that there is little understanding of the distress that the different staffs are experiencing. They agree to trade staff one nurse at a time so they can appreciate the work of the others. It is in that project that they discover that their goals were different. While an inpatient unit wants the ability to say, “We can’t take any more admissions,” the ER staff are complaining that they don’t have that option. People keep coming in the door because they need care. So a conflict begins over who will help the ER in time of need. With everyone lacking resources under these circumstances, the conflict only escalates. Subsequent meetings are held on developing common goals: “Taking care of the community we are here to serve.” Other goals focus on “what is best for the patient” and “who is in a position to determine where the patient should be under these stressful circumstances.” As the tension in the group comes down, they are able to do some joint problem solving to avoid such intense conflicts in the future. They agree on criteria for transfer as well as times for transfer that would be less stressful for everyone. They agree that everyone will pull together to get the patient admitted within 30-60 minutes of a decision to admit. Negotiation is the name of the game.

Resolution is on its way through role clarification, mutual goal setting, compromise, collaboration and understanding each other’s hot buttons. Each specific unit continues to improve staffing levels to more readily meet the needs that arise with call-in procedures and improved unit-level teamwork. Attitudes improve greatly as the solutions fall into place. They discover a win/win set of strategies.

Relationship management

As we have seen above, positive interdepartmental relationships must be established and nurtured. At the operational level closest to the patient, it is usually the job of the nurse to take on that responsibility. The charge nurse is most frequently the one who is calling the pharmacy, the lab or respiratory therapy to get services and supplies delivered so the patient’s care can move forward in a timely and therapeutic manner. It does no good to become impatient or defensive when delays occur. If there is opportunity to express urgency and concern for the consequences of delay to the department with an open mind to their stress, the spirit of common goals and teamwork will more likely prevail. Attitude is everything. Keeping an open mind is paramount to that objective. Susan certainly exercises that principle when working with the ER when she admits Mr. Hagen to 5West. She endeavors to understand the ER’s situation and to offer a helping hand in the midst of a full load of patients on her unit. Kate, on the other hand, fails to understand the ER. She is so afraid of the pharmacy and the potential conflict in a phone call that she closes down communication by scolding. The patient is at risk because he receives his antibiotics five hours after the physician’s order.

The subsequent scene for Kate is to deal with an angry physician who discovers that his patient’s care is delayed. It does her no good to blame it on the pharmacy or on the ER and their ordering system. A better approach is for Kate to call the physician to report the delay. Appropriate patient data about his status allows the physician to decide on any altered patient intervention. Hiding from conflict is always the wrong decision. Working with an attitude of teamwork and continuous improvement reduces the disruption of conflict. Positive problem solving and a win/win strategy result. Teamwork includes the necessity of having critical information and assessments of the patient before calling his doctor to solve a problem. The charge nurse is in a position to support the staff with their critical-thinking skills and with organization of information in preparation for discussing the problem with the doctor. The charge nurse can be a model for positive communication with medical staff.

In today’s environment the patient’s length of stay is very short. Staffed beds are scarce. There is a shortage of nurses to care for an increasing number of patients arriving at the hospital. The frustration levels of the nursing staff are on edge. The restriction of resources to accomplish a critical level of care makes the workload more intense and the staff less confident that they are doing their best for patients. The best solution to stabilizing the staff and maintaining some sense of fulfillment is to create an open atmosphere of communication. On 5West Susan gets to know each of her staff members and understands what he or she needs. She must be flexible and enlist team spirit to help meet each other’s needs in a positive way. The more she involves the staff in the decisions that need to be made in the way the shift is run, the more control they feel over their work environment. A participative process provides a team that is intrinsically committed to the goals of the unit and to patient care. The resulting motivation results in reduced turnover, fewer call-ins and a more positive attitude by all. To accomplish such a goal, Susan must be sure she meets with each of her staff once or twice per month, if even for 10 minutes. She discovers what each nurse really wants and needs in his or her clinical practice. She discovers where each nurse wants to go in his or her career and what he or she needs to ensure appropriate attention to family and personal life. Such empowering attention builds mutual respect, trust, loyalty and teamwork. Working closely with the nurse manager to create a positive environment helps the unit as a whole and leads to improved shift-to-shift communication.

Susan’s transition is not without its challenges. The support and coaching of her manager as well as ongoing education in the interpersonal skills of leadership, management, coaching, and negotiation are essential to her success. She becomes comfortable with the skills it takes to meet the role expectations. The manager begins introducing her to the task-oriented aspects of management. She is oriented to the monthly financial statement for the unit and to the formal written evaluation of progress toward unit goals.

Making the transition from staff nurse to charge nurse is an expansion of skills the experienced staff nurse has already developed. Planning, organizing, implementing and evaluating patient care is the universal nursing process. Critical thinking, conflict management and relationship management are leadership and management skills that experienced nurses use in coordinating their patients’ care. Expanding these skills to include the coordination of the entire unit appears daunting at first. With the support of the unit manager as coach, the implementation of the concepts is familiar. The charge nurse has the opportunity to provide the leadership and teamwork that enhance patient care and increase her own professional fulfillment.

Chapter 3
Supervising and Coaching

Nora is a 28-year-old nurses assistant on 5W. Her husband has a job in a packing plant, and they have three children, two of whom are in school. Nora is expected to be at work at 7 AM Her husband drops her off on his way to work, while her mother prepares the children for school.

This morning Nora arrived at work at 6:50 AM and discovered that she had left her name badge in the car. She found the night supervisor and explained the problem. The supervisor became angry, telling Nora that she would have to go home and relinquish the day’s work and a day’s pay. Hospital policy firmly states that there can be only one name badge per person, the supervisor said. The supervisor further stated that she hoped this incident would “teach Nora a lesson.”

Others in Nora’s position might have relished having the day off. But this was not the case for Nora. She was very concerned about Mr. Hagen, and she knew her help would be needed to adequately care for him. Most likely there would be at least one less aide on the floor that day, as had been the case nearly every day in the last two weeks.

Equally important, losing a day’s pay would be a disaster for Nora's family. Both she and her husband earn less than $8 an hour, and they support their three young children and her mother.

By 8 AM Nora was in tears as she talked with a group of friends in the cafeteria. She told the story in great detail, sounding like a victimized employee and describing the supervisor as cruel and angry. Nora's bitterness was palpable.

Charge nurse as coach

Nora’s story illustrates the impact and significance of poor supervisory skills and the potential of coaching as the preferred skill set to use in many circumstances. A charge nurse who is in a supervisory role, even temporarily, can be more successful more often when she uses coaching skills with her colleagues. In the instance above, Nora’s night supervisor may have been tired from a long and demanding shift, but that is no excuse for treating Nora in a shame-based, fear-producing manner. The cost of that behavior was that Nora became a disgruntled employee. And the cost of disgruntled employees is enormous, if difficult to measure. In this instance, Nora’s behavior tainted other employees in the hospital because she interjected her own feelings and experience. Unfortunately, this is not unusual.

Benefits of coaching

Coaching skills can greatly benefit nurses, even in the most difficult of supervising challenges. First, the supervisor and his or her colleagues will produce better outcomes when their relationships are healthy, when they are clearly communicating without blame, when there is an atmosphere of interpersonal trust, and when there is an ethic and practice of teamwork. Nurses enjoy better relationships with both colleagues and subordinates when their approach to one another is respectful and valuing. Such an approach gives them all greater satisfaction while they are on the job.

The table illustrates the challenge that Nora presented to her supervisor and two approaches her supervisor could have used to address this challenge. The first approach is an ill-considered, emotional response. The second approach employs coaching skills. The coaching response takes Nora’s wishes into account, acknowledges Nora’s feelings of disappointment and honors her intention to quickly correct the problem.

Key coaching skills

The coaching responses listed above can help create a positive work climate for Nora. All RNs with supervisory responsibilities can use the basic coaching skills that underlie these responses.

Each coaching skill that follows can be used in most circumstances in which others must learn how to be successful. For example, perhaps a person does not know what the desired behavior is. In this circumstance, the coach/supervisor will instruct and direct the person, describing the desired outcome and behavior. The coach/supervisor will be patient, supportive, specific, and clear as he or she instructs the “coachee” on the desired performance. The coach/supervisor will describe the goal and demonstrate the behavior. He or she will communicate in a straightforward way and will not infuse his or her demeanor or words with emotions such as anger or frustration.

In a different learning circumstance, the coach/supervisor may not be instructing the person for the first time. Perhaps the “coachee” has forgotten the desired behavior and needs a refresher course. Perhaps the “coachee” has the basic competence to perform the task, but requires supervisory attention to raise his or her level of performance. In either of these instances, the supervisor/coach will want to match the needs of the person with the support the coach provides. In addition, the coach will want to be available and open in his or her communication style, clear in his or her demonstration of the skill and patient with the “coachee” as the “coachee” learns or re-learns.

Relationship development

Let's assume that Nora is an employee who consistently arrives on time and that she is generally prepared for and eager to perform her work as a nurses assistant. During the current nursing shortage at the hospital, Nora’s services are more valuable than ever. A nurse who is Nora’s manager will go a long way if she appreciates her staff’s commitment and service. By acknowledging Nora in this way, her supervisor will contribute more to patients, more to Nora, more to the unit’s culture and more to the organization.

An important quality in successful relationships is trust. Nora is much more likely to trust her supervisor if that supervisor recognizes her consistently good work ethic and performance. Yet, the opening scenario clearly demonstrates an absence of trust and the resulting strained and difficult relationship between Nora and the night supervisor.

This poor relationship has tainted Nora’s attitude. It is certainly possible that Nora will seek employment elsewhere. Additionally, the night supervisor’s treatment of Nora has also negatively affected Nora’s friends — also employees. Thus, the supervisor’s ill-considered behavior reaps immediate and perhaps long-term consequences throughout the organization.

Colleague vs. expert

Relationships are most healthy when people respect one another. An atmosphere of respect is particularly important when colleagues must work side by side, whether caring for patients or learning from one another. Supervisors often have greater experience and expertise, and as patient care needs change, these supervisors may need to train their staff “on the spot.”

Fostering good relationships when peers work together as fellow professionals is relatively easy, but when one nurse is in a supervisory role or when he or she is instructing another, relationships can break down. This is a likely outcome if the teaching individual does not approach the other individual with respect and dignity at all times. It is especially helpful if the supervisor or teacher remembers that he or she needed to learn this same skill once. While the supervisor or teacher is in a teaching “role” today, he or she is also a colleague and fellow professional. Relationships that include a teaching and supervisory component are especially healthy when communication between the parties is also healthy.

Communication

Good communication is key to working with others. It promotes productive relationships among team members, and it is essential for smooth transitions from one shift to another.

Keys to successful communication include:

• Open lines of communication between staff and supervisory nurses
• Respect and credibility among team members
• Clear statements demonstrating desired outcomes and processes for achieving them
• Good listening skills among all parties to a given communication
• Well-articulated requests, responses, statements and questions that convey important information to both parties.

When behavior requires correction

When an employee behaves inappropriately, communication should be timely, explicit, direct and uncompromising. The supervisor will want to clearly state the nature of the inappropriate action and will need to clearly articulate the desired behavior or remedy for the problem. In the absence of such specificity, it is difficult for employees to understand what has gone wrong and what they must do to rectify the problem.

Such communication need not be emotion-ridden. Recall that Nora’s supervisor was “angry.” Infusing the supervisory message with anger clouded Nora’s ability to think well and react positively. She was unable to problem solve on her own behalf. Instead of finding a way to work that day, Nora tearfully repeated the details of the entire incident to her friends in the hospital cafeteria.

Using a coaching approach, a supervisor can work quite differently with an employee. As a peer, he or she can teach the employee the missing skill or can calmly discuss the problem. For example, if Nora’s supervisor had taken a coach-like approach, she would have noticed that Nora is a faithful employee with a good work record. Nora simply made a mistake that day. The supervisor could have behaved in the manner noted in the “coaching response” column in the table on page 19. She could have taken Nora’s good record into account, reflected that back to Nora, and problem solved with her so she could report to work as soon as possible.

Guidelines for feedback

In many instances, nurses in supervisory roles must provide feedback for staff members. Feedback is appropriate in many situations, such as the need to appreciate staff for their contributions, to promote and teach different behaviors and to understand the consequences of failing to deliver these outcomes and behaviors.

The table below offers supervisors, managers and all nurses guidelines for effective feedback.

Supervisors who would like to incorporate a coaching approach into their feedback can also use the guidelines on the next page.

Listening

Listening is one of the most important skills for a nurse in a supervisory role. It is particularly vital because most people in our society have not been taught to listen well. People often believe they are listening, but they are actually focusing mostly on themselves and their own internal conversation.

This internal conversation can create a set of filters through which we hear another's words. There are many examples of listening filters. These include impatience (“Get to the point”); guessing what the person will say next (“Let me finish your sentence for you”); listening for how the person is wrong (“Gotcha!”); approving or disapproving of what’s being said (“I’m right and you’re wrong”); and listening and responding to “look good” (“I know better”).

These listening styles backfire because they prevent the listener from focusing on the person who is speaking. The listener not only misses what is actually being communicated, but also unconsciously conveys disrespect to the person who is speaking.

The table “How to Listen” on the next page offers an alternative way in which to listen. This alternative creates filters, as well, but these “filters” convey trust and enhance the relationship between the speaker and the listener.

Patience

Patience is inherent in good listening, effective coaching and healthy relationships. Nurses are trained to be patient with people in their care, and it is equally important for nurses to be patient with colleagues and other staff. Without patience, good relationships and effective communication become strained. Yes, it is difficult to be patient in a fast-moving, stressful environment. But patience is even more critical in those times. In stressful moments, it is all too easy to make costly mistakes and errors in judgment about patient care.
Imagine, for example, how different the outcome would have been if the night supervisor had been patient when Nora presented her problem. It is likely that Nora would have found a solution to her mistake more quickly, she would have gotten to work faster, and she would have felt less resentment toward her supervisor. She also would not have had the reason or the opportunity to discuss her unhappiness with her friends in the hospital.

Reflection

The charge nurse will benefit from reflecting in at least two circumstances:

1.  From time to time, it will be important for her to “hold up the mirror” to people reporting to her.  As with feedback, this may mean appreciating something the person has done particularly well. Or it may mean reflecting back inappropriate behavior. 

In this instance, it is most helpful to reflect such an incident by using the principles of feedback, by asking a question, or by stating what you are conveying with an “I” statement.

For example, if you were supervising Nora’s supervisor, you might say, “When you stated to Nora that you hoped this incident would ‘teach her a lesson,’ I became concerned that you were not communicating respectfully with Nora.”

2.  As a supervisor, it is important to review your own actions before you take them and after they are completed. You will offer your best guidance if you learn through reflecting on the effectiveness of your activities. Supervisors can learn a great deal about the success of their work by taking a few minutes to reflect on results and feedback messages they have received throughout the day. 

Valuing

Managing successfully requires adopting an attitude of conscious respect for colleagues on the unit and in the organization. People know when other people value and respect them. They also know when value and respect are not present, and they will not do their best work in such circumstances. Unconsciously, they may feel disrespected, and thus they may expend energy on trying to improve your opinion of them, rather than caring for patients with all their energy and focus.

Charge nurse as supervisor

In the seminal 1985 book Leadership and the One Minute Manager, the authors describe four management approaches in leadership styles: directing, coaching, supporting and delegating.³ These styles use different combinations of two basic behaviors: directive and supportive. Directive behavior involves structure, control, and supervision. Supportive behavior involves praise, listening, and facilitation. The authors advise that in deciding which style to use, managers must assess the competence, knowledge, skills and commitment of the individual.³ As we have seen, solid peer relationships based on coaching principles will promote healthy relationships between staff and supervisors.

In addition, supervisory roles often carry unit or organizational cultural expectations. The table shows some of the time-honored expectations and roles of supervisors.

Supervisory styles

Two supervisory styles can be starkly contrasted (see table on next page.)  The “boss” style is a dominant, “pushy” style that encourages others to “follow directions.” Unfortunately, an unintended consequence of this approach is that it encourages a lack of responsibility and accountability in others. In patient care settings, this is a consequence we can ill afford.

Still, there are times when it is appropriate to use the more authoritarian style. Examples include patient emergencies that involve staff members who are not sufficiently trained to independently judge the best course of action. For instance, when a code is called, the most experienced clinician is always the code captain. That clinician may ask questions of the primary nurse to broaden the database for making decisions, but there is one distinct leader who gives the orders and orchestrates the resuscitation. When the hospital code team arrives (specialists in resuscitation), the unit team moves to let the code team leader take over with their subsequent interventions from the crash cart as necessary. The team leader is in “boss” mode appropriately, and out of necessity. An effective code team will return to the unit’s staff to review the code with staff and discuss ways the process could have been improved. This subsequent review is a “coaching/teaching/evaluation” mode and is critical to the continuous improvement of patient care.

 Supervisory relationships

The quality of supervisory relationships affects staff motivation and commitment, teamwork, and patient care. For example, Nora’s story clearly illustrates how a supervisor can enhance or diminish an employee’s motivation and commitment. Because Nora was unable to start work until much later in the day, Mr. Hagen’s care may also have suffered. Finally, the nurses on the unit did not benefit from the assistance that they needed from Nora until late in the shift.

Nora’s night supervisor would have been more successful if she had considered the motivators in the table above to help Nora and the patient care team achieve their professional and personal goals for the day. 

Conclusion

In this chapter we have explored the far-reaching consequences of an ill-considered supervisory style. We have explored alternatives to the hasty approaches of “teaching by telling” and shaming employees when they make a mistake, even in fast-moving, pressure-filled environments. We have discussed the benefits of using a “coaching” approach instead. We have seen how such an approach can nurture relationships, open communication, encourage mutual learning and foster better patient care. We have learned how to provide feedback and to listen with discernment and respect.

Chapter 4
Delegation and Teamwork

Delegation is a critical skill for today’s nurses, regardless of their position in the organization. Staff nurses on a general unit in a hospital will be working with nurses assistants who will help them with the nursing care of their patients. For charge nurses like Susan, delegation options also include the staff members on the whole shift. Susan’s delegation skills go hand-in-hand with her planning and organizing skills so that her patients are appropriately cared for, clinically and personally.

Delegation can be defined as getting work done through others in order to meet the goals of the unit.¹ For the staff nurse, delegation is the authorization by a registered nurse to an unlicensed person to provide selected nursing services.²

There are several examples of Susan’s sound delegating skills in Chapter 2. The most significant is the assignment of patients to specific nurses and their nurses assistants. As the nurse in charge, Susan has the legal responsibility for the appropriate delegation of services for safe care. In the assessment of resources, she is careful to match patient needs with the expertise of specific nurses. She is also aware that the nurses assistants have different skills and unique relationships with each other. In addition, Susan identifies an opportunity to expand a nurse’s practice by delegating the teaching of the use of the PCA pump to a highly competent nurse with appropriate experience. Another nurse then gains valuable experience in caring for postoperative patients with hip replacements. In each and every case, Susan knows the skills of the people to whom she is delegating and matches those skills to patient needs.

Delegating and decision making

Delegating patient care puts the charge nurse in the role of constant decision maker. She must assess, plan, and organize the care just as she did as a staff nurse, but the scope of her delegation is not for six to eight patients but for all on the unit. She must make decisions about which staff member is best suited to care for each patient.

In making these decisions, she considers the following factors:

• Clinical needs of a particular patient
• Clinical competencies and specialty of each nurse
• Any physical limitations of staff members
• Value of continuity for the patient and the nurse
• Intensity of care needed for the patient group (i.e., workload)
• Experience and skills of the nurse assistant on each team
• Skills needed for the patients coming from the PACU and the ER
• Potential education and supervision needs of less experienced staff
• Physical location of the patients in the assigned group

Susan, for example, has empowered the staff by continuing the practice of negotiating to bring forward their better ideas and more efficient ways of managing the caseload. As she makes rounds with the staff, she creates the opportunity for team members to review expectations for the shift and ensures that the standards of the unit are met. As she makes rounds at the end of the shift, she folds the evaluation of care and delegation into her conversations with the patient and the nurse as she reports to the oncoming shift charge nurse.

On 5West the walk-about rounds with staff serve several purposes. The primary goal is to include the patient in the care planning process. In the delegation process, the rounding serves as an opportunity to communicate with all concerned about the plan of care and shared expectations at the beginning of the shift. The evaluation at the end also includes the patient’s evaluation.

Many patient care units have used the time-efficient tape-recorded report for end of shift reporting. This approach has the effect of reducing potential overtime for the off-going shift and theoretically reduces the social chitchat time between nurses. The disadvantages include:

• Reinforces the task-oriented “lets get through this shift so we can go home” mentality.
• Eliminates useful dialog, teaching, and collaboration between the patient, his or her nurse, the charge nurse, and the oncoming shift nurse.
• Eliminates the opportunity to negotiate and clarify expectations.
• Eliminates the opportunity for the on-coming staff to ask questions about the plan for the shift or to make suggestions about changes in the plan of care.
• Is not patient-centered.

The walk-about reporting approach provides an efficient opportunity to enhance appropriate and safe delegation as well as smooth teamwork that includes the patient as part of the team.

Benefits of delegation

Delegation can empower staff, generate greater commitment, and foster professional growth and pride. Benefits of effective delegation include:

• Patients can have personal care needs met more quickly.
• RNs can devote their time to those activities that require their skills, such as patient care coordination, treatment, and evaluation.
• RNs can experience greater job satisfaction because they don’t have to do everything themselves and they feel supported.³
• Nurses assistants can strengthen their clinical skills within the scopes of their practices.
• Nurses assistants can expand their capacity to contribute and achieve greater job satisfaction.

It is important to keep the mission, vision, and values of the unit in mind, as well as the goals and values of the team members. This ensures that delegation is in fact contributing to individual growth and professional satisfaction, as well as getting the job done. If this is attended to, the delegating nurse will create an environment of empowerment, a people-centered culture, better patient outcomes, and more satisfied professional staff. Susan, for example, produces this atmosphere for two nurses (in Chapter 2) when she delegates the postoperative patient to an expert nurse along with a nurse needing additional experience.

Underdelegation

Clare has been taking care of Mr. Hagen for three days with Nora’s support. Clare knows that Nora is an experienced and reliable nurses assistant. She has been seeing to Mr. Hagen’s personal care and collecting his vital signs while keeping Clare informed. When the plans for improving Mr. Hagen’s pain control were made, Clare decided to reduce his anxiety by increasing skin care and back rubs to three times per day. Initially Clare did these herself because she gained satisfaction from seeing Mr. Hagen relax and ultimately reduce his need for analgesics. However, Clare began running behind with the care of her other patients. In reviewing the problem  with Susan, she elected to delegate the skincare to Nora, who was well equipped to follow through. At the end of the shift, both Mr. Hagen and Nora reported that the care was going well and continued to help him with pain control.

Many staff nurses have come out of education programs and experience in which all the tasks of patient care were expected to be completed by the RN. But today, with severe shortages, nurses must learn how to delegate safely and comfortably. Many nurses have a tendency to “underdelegate” because of insecurities about the competency of support staff. The nurse must understand the extent of the competencies of support staff with whom she is working. She must also acknowledge the limitations of their training programs.

She will want to reinforce for them that she is responsible for the assessment, planning and delivery, and evaluation of care. The critical thinking skills that she has developed as part of her clinical training will prepare her for this responsibility. The support staff are trained to provide limited technical skills in personal care and in collecting selected noninvasive technical data such as vital signs. It is essential that the nurses assistants share their data with their nurse in order to ensure that the nurse has a complete picture of the patient’s status and progress.

Overdelegation

When Mr. Hagen needed to be admitted, Susan was very aware of the chaos in the ER. When she assessed the workload of all the staff present on 5W, she saw that Nora would be able to go the ER to complete the transfer. Susan herself was very busy with new orders and stat deliveries from the pharmacy. The temptation to send Nora was great. As her critical-thinking skills kicked in, however, Susan knew she would be overdelegating. Like most patients coming from the ER, Mr. Hagen was very sick, short of breath, and in pain. There was a risk for him to code.

So, Susan elected to complete the transfer of Mr. Hagen herself. She asked Clare to be available to the unit clerk for support if she needed assistance. When she returned from the ER with Mr. Hagen, Clare was still barely keeping up with her patient load. Rather than delegate the admission to Clare as planned, Susan decided to admit this patient herself, not because Clare didn’t have the skills, but because she didn’t have the time. Susan knew that Mr. Hagen’s antibiotics and pain control needed immediate attention and that Clare was involved with other critical issues with another patient.

Susan avoided overdelegation in both of these examples. Because Susan as delegator is responsible for the outcomes in these instances, she knew that it was her obligation to cover Mr. Hagen for both transfer and for admission. She used the techniques in the table below to lead her to the best delegation decision.

When delegation occurs, who is responsible? Nurses are ultimately responsible for the outcomes of the work done by the delegatees. Equally important, delegating is decision making in action. What is decision making? It’s choosing between alternative courses of action. In fact, delegation involves a constant stream of decisions, so understanding the elements of good decision making and critical thinking are very important. A helpful tool for staff who are being delegated to is to ask them to think through the best case/worst case and probable case scenario of the decision they are contemplating.⁶ Delegation takes practice. If Susan had not been skillful at critical thinking, she might have made the wrong decision. As new delegaters build their confidence through continuing practice, they will want to review their delegation decisions with their managers for feedback.

Delegation and empowerment

Appropriate delegation offers many opportunities for empowering staff. Empowerment means to enable and develop. It is an interactive process that develops, builds, and increases power through cooperation, sharing, and working together.¹ Self-scheduling is an empowering process developed by a team that works through the scheduling criteria to meet the goals of the unit. Some of the criteria are safety-related and other criteria are related to equity among staff members. Facilitation is provided by the nurse manager who coaches the team by asking critical questions. She also describes scenarios so they can test their assumptions and the design. Staff are oriented to the process and encouraged to critique that process.

Open communication and a positive attitude are key to empowering delegation. Competition and tension must be set aside so that the best design can be brought forward. If the manager needs too much control, she will be unsuccessful at empowering their staff. She will have to move from “boss” mentality to “coach” perspective to facilitate the process for empowerment. Trust is a key component because staff will resent the work of designing the process if the manager single-handedly overrides the decisions they make without building consensus on the issues.

The manager has basically delegated the scheduling process to her staff. In so doing, she has given them more control over their work environment and has facilitated a smooth teamwork process where positive and enabling attitudes prevail. While the team and the staff are responsible for the schedule, the manager is still ultimately responsible for scheduling and will evaluate each schedule they produce. She will provide constructive feedback and an encouraging evaluation of the process while confidence builds. For those who are resistant to change, she may decide to use a coaching approach. Together, they will assess the barriers to implementation and better understand the staff’s needs.

The hospital code team holds a wonderful opportunity for empowering staff on a unit as they review and critique an incident post-code. The unit staff, out of necessity, is delegated the responsibility for resuscitation at the beginning of a code. The designated leader assumes the job of giving orders so that the code runs smoothly and time is not wasted. When members of the code team arrive with their additional expertise, they take over the leadership with the support of the unit staff. The postcode review is a teaching opportunity that reviews and evaluates the delegation and the decisions that were made from beginning to end of the event. The code team leader, rather than point fingers, uses this opportunity to reinforce the positive wisdom of some decisions and to explore alternatives for things that could have been done better. The next time, the code will likely go better and the staff will be more confident in their decisions. The code team leader moves from “boss” to “coach” in the review process, giving the staff an opportunity to expand on the circumstantial variables surrounding the deterioration of the patient and their subsequent decisions in calling and running the code. This scenario is an enabling and interactive process that develops, builds, and increases power through cooperation, sharing and working together. It builds confidence and supports the continuous improvement of patient care.

The charge nurse has many daily opportunities for empowering staff. He or she will make increasing progress toward that goal if it is held as a value and a goal of the unit and the institution. The charge nurse’s ability to delegate appropriately while empowering and developing staff is increased when the charge nurse reviews opportunities with his or her manager.

Delegating up and down

When delegating functions down or across the unit staff, the charge nurse uses the following criteria to make decisions about what to delegate and to whom to delegate it. It is important to note that these are the same criteria we have seen in previous examples of delegation:

• Plan ahead to identify tasks to accomplish.
• Assess the patient need (including anticipatory needs).
• Identify the clinical skill to meet the need.
• Assess the time needed to accomplish the care.
• Assess the supervision available to ensure safe performance.⁷

The standards for delegation should be part of the unit standards and expectations and can be used by charge and staff alike to make appropriate decisions. One major concern during this time of shortages is the temptation to overdelegate to supportive personnel.

Mrs. Petrie is a 92-year-old debilitated patient transferred to 5West from a nursing home. She has had six admissions in the last year. Her incontinence, sacral pressure areas, and disorientation make her nursing care needs high. Elise, her RN, has been caring for her along with the support of the nurses assistant, Donna, for the last several days. Donna is a competent nurses assistant with extensive experience. Because of the demands on the staff, Elise has asked Donna to turn Mrs. Petrie and change her sacral dressing. Donna accepted the challenge and followed instructions. The next day when Elise changed the dressing herself, she discovered that the pressure area had enlarged and there were signs that the infection was worse.

Why was this overdelegation? Elise, although pressed for time and in need of help, chose an unlicensed assistant to help her with a clinical task. Elise gave the responsibility for the nursing judgment to an assistant who did not have the preparation to assess, evaluate, or take nursing action. She put the nurses assistant in the awkward position of feeling uncooperative if she didn’t do as requested.

What might have been a more appropriate decision? One option is to delegate up! She should have asked Susan, her charge nurse, to change the dressing, evaluate the decubitus, and report to her with suggestions for any change in the plan of care. In so doing, she would have asked a clinically competent nurse to accomplish a patient care goal without giving away her responsibility for the patient’s total care. If Susan had no recent experience in managing decubiti, she might have delegated across the unit to Ellen, another nurse who has strong surgical skills, to accomplish this task or at least asked her for her clinical assessment of the wound.

Delegating up does not reflect incompetence. Delegating inappropriately is potentially dangerous. Accepting an assignment for which one is not clinically prepared or current is equally dangerous. Using the criteria for delegating and accepting tasks delegated is important to the safety of patient care and for the smooth functioning of the team. If the trust within the team is low and team members are stressed and intimidated like Donna, the risk of accepting inappropriate delegated tasks increases. There is risk that the safety of the patients will be compromised.

The quality of communication on a patient care unit sets the stage for success or failure in delegation, empowerment and trust building. Appropriate decision making can be strengthened with strong communication and negotiation. Susan would have modeled teamwork and empowerment if she had decided to ask Ellen to help her with Mrs. Petrie. By demonstrating that eve