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Running head: BEING A NURSE MANAGER

Being a Nurse Manager

Anne M. Hendricks

Ferris State University

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INSERT RUNNING HEAD P2 HERE

Abstract

This paper explores the challenges of being a nurse leader or nurse manager in today’s healthcare

system. Analysis of leadership and management was provided. Comparisons were made through

personal communications with a nurse manager and research. Interviews with Carol Baker,

nurse manager of C4 at Munson Medical Center, Traverse City Michigan provided much of the

information. An introduction of Ms. Baker including her education, years in practice, and

additional qualifications was provided. Analysis of Ms. Baker’s handling of cultural diversity on

the unit, legal issues, use of power and influence, decision-making and problem-solving process,

managing conflict, and participating in research were explored. The effect on the staff, patients

and organization were included in the analysis. Comparison and support of Ms. Baker was

provided from research from several sources. The project allowed me to analyze the challenges

of being an effective nurse leader and to recognize how a good leader can affect staff, patients

and the organization.

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Being a Nurse Manager

Being an effective nurse manager/leader in today’s healthcare environment is important

for many reasons. Patient satisfaction, employee satisfaction and success of the organization

depend upon it. According to Ellis and Hartley (2009), a leader guides, teaches, motivates, and

directs the activities of others toward attaining certain goals. A manager is an appointed person

that coordinates and integrates resources through planning, organizing, directing and controlling

to achieve specific goals within an organization (Ellis & Hartley, 2009). A manager is

responsible and accountable for the goals of the organization. A good manager generally also

possesses good leadership skills through the ability to empower others (Ellis & Hartley, 2009).

Introduction of the Manager

I interviewed Carol Baker RN, OCN manager of C4 at Munson Medical Center Traverse

City, MI. 49684. Ms. Baker introduced herself:

I have been a nurse for 27 years, starting as an LPN on the oncology unit at Munson

Medical Center. I received my Associates degree in 1986 from Northwestern Michigan

College and my Bachelor of Science in nursing degree in 2001 from Graceland

University. My focus in nursing has been in Oncology, both inpatient and radiation. In

1999, I became the Nurse Manager of a 21-bed oncology unit and cancer registry

department. Last year I decided to begin a Masters in nursing program on the

management and leadership track, I plan to graduate October 2011. I have been certified

as an oncology nurse for twenty years as I feel very strongly that this adds to the

profession of nursing, encouraging nurses to do the same (C. Baker, personal

communication, October 21, 2010).

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Cultural Diversity

According to the United States Department of Health and Human Services (USDHHS)

(2001), culture is “integrated patterns of behavior including language, thoughts, communications,

actions, customs, beliefs, values and institutions of racial, ethnic, religious, or social groups”

(p.2). It is important for nursing to recognize that culture has an impact on health care beliefs,

perceptions of health and illness, health practices and disease prevention (Ellis & Hartley, 2009).

There are challenges to overcome in order to be a culturally competent nurse. Having the

knowledge of clinical differences of health practices of different groups, and the ability to

communicate effectively with different groups are two important tasks of the culturally

competent nurse (Ellis & Hartley, 2009).

The Smudging Ceremony

Per our personal communication (October 21, 2010), Carol Baker stated that cultural

diversity has been an issue on the oncology unit when taking care of many Native Americans at

the end of life. Ms. Baker approached her superior to see if some of the rules of the hospital

could be adjusted to perform the “smudging ceremony” (personal communication, October 21,

2010). The method for performing the ceremony is to burn certain herbs, take the smoke in one's

hands and rub or brush it over the body, especially onto areas that need spiritual healing (Borden

& Coyote, n. d.). The power of the herb is believed to cleanse the spirit (Borden & Coyote, n.

d.). Native Americans believe that before a person can be healed, heal another, or die peacefully

one must be cleansed of any bad feelings, negative thoughts, bad spirits or negative energy

(Borden & Coyote, n. d.). The institution waived the non -burning rule for the ceremony to be

performed (C. Baker, personal communication, October 21, 2010).

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Effect on patients. Developing trust is one outcome of culturally competent care (Ellis &

Hartley, 2009). Although there is no specific data recorded at Munson to support the Native

American patient satisfaction, there are studies to support cultural care. Explanatory,

compassionate healthcare providers who took into consideration Native American culture

influenced the participants' sense of well-being (Lackner, 2009). Providing culturally congruent

nursing care could reduce suffering, and decrease morbidity and mortality rates reported among

Native Americans, thus decreasing disparities in healthcare outcomes among minority

populations (Lackner, 2009).

Organizational Support of Cultural Diversity

According to the USDHHS (2001), organizations must be competent in caring for

differing cultures. The areas of competence are cultural competence, language access services,

and organizational support for cultural competence (USDHHS, 2001).

Ms. Baker states that her unit has a book titled Culture & Nursing Care that is used

frequently to help nurses attain cultural competence (personal communication, November 10,

2010). The hospital also has general education through Health Stream, which encourages

awareness and resources to care for different cultures (Munson Healthcare, 2010d). All

employees must complete Health Stream on an annual basis to remain employed ( C.Baker,

personal communication, October 21, 2010).

Caring for the elderly is a special consideration on C4 because a majority of the patients

are geriatric (C. Baker, personal communication, October 21, 2010). In 2005, 17% of the

Munson area was 65 years or older (Munson Community Health Department, 2008). This is

about one third higher than the proportion for the State and the U.S. as a whole (Munson

Community Health Department, 2008). Ms. Baker states that the unit is going to introduce a

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new program to focus on care for the geriatric patient (personal communication, October 21,

2010).

The NICHE program (nurses improving care for health system elderly), is going to be

introduced to C4 in the near future (Boltz, et al., 2008). The program will provide education to

staff regarding care specifically focused on geriatric patient needs (C. Baker, personal

communication, October 21, 2010).

C. Baker states that, “Nurse Leaders have to be sensitive to issues related to culture, race,

gender, sexual orientation, and economic situations among staff and patients” (personal

communication, November 15, 2010). Munson supports cultural care and was awarded the

Magnet designation recognizing excellence in patient care standards, respect of cultural and

ethnic diversity, leadership of the nurse administrator in supporting professional nursing practice,

and the management and philosophy of nursing services (Munson Healthcare, 2010c)

Patient Safety a Legal Issue

Patient safety is an area that requires much attention from management because it can

lead to legal issues (C. Baker, personal communication, November 15, 2010). Medicare will no

longer reimburse hospitals for a higher-paying DRG (Diagnosis-related group) when one of eight

selected hospital-acquired conditions develops during the hospital stay (Clancy, 2010).

Hospital falls and trauma were included as one of the eight conditions that the Center for

Medicare and Medicaid Services (CMS) argues, “Should not occur after admission to the

hospital.” (Inouye, Brown & Tinetti, 2009). The CMS heralded this move as an effort to align

financial incentives with the quality of care, thereby promoting both quality and efficiency

(Inouye et al. 2009).

Some 3 to 20% of inpatients fall at least once during their hospital stay; these falls result

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in injuries, increased lengths of stay, malpractice lawsuits, and more than $4,000 in excess

charges per hospitalization (Inouye et al. 2009). Each year, about one third of persons who are

65 years of age or older living in community settings fall at least once; the percentage is 50%

among those 80 years of age or older (Inouye et al. 2009).

Keeping Patients Safe on C4

A patient safety initiative was piloted on C4 back in 2009. The program ARTT

(ambulating, rounding, toileting and turning) was put in place as part of a national patient safety

initiative (Munson Healthcare, 2010). The staff was required to round hourly on each patient

and log the round on a chart kept on the patient chart. Other ancillary services also could record

their visit on the chart. The amount of falls was then logged. Because of the pilot, C4 had a

record setting 180 days without a patient fall (R. Stanton, personal communication, November

29, 2010).

Effects on staff, patients and institution. The staff felt that the ARTT program cut

down on interruptions because the rounds were planned and divided up among staff rather than

unplanned (C. Baker, personal communication, November 16, 2010). The rest of the hospital

adopted the initiative on all units on March 19, 2010. The results are yet to be tallied, but patient

satisfaction scores seem to support the hourly rounding (Munson Healthcare, 2010b). The Joint

Commission passed the hospital and did recognize the patient safety initiative in July 2010

(Munson Healthcare, 2010a). According to Ellis and Hartley (2009), the Joint Commission has

standards for all aspects of care, structure, process and outcomes that must be achieved in order

to pass.

Use of Power and Influence

The nurse leader should be a role model for staff as well as other managers (C. Baker,

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personal communication, October 21, 2010). C. Baker believes that her encouragement of nurses

to certify, achieve clinical advancement as well as perform peer review has positive effects on

the nursing unit (C. Baker, personal communication, October 21, 2010).

Encouraging Leadership through Clinical Advancement

Nursing staff should learn to be leaders and the career advancement system in the

hospital encourages this (C. Baker, personal communication, October 21, 2010). The Clinical

Advancement System was developed in 1989 to keep the expert nurse at the "bedside" in his/her

specialty area (Munson Medical Center, 2010)

Clinical advancement effects on staff, patients and institution. When a nurse

successfully completes the Clinical Advancement System at Munson he/she is rewarded through

a pay increase of $1-$2, depending upon level achieved (Munson Medical Center, 2010). The

clinical advancement rewards nurses for taking on more responsibilities, which should lead to

improved patient care. The system also keeps nurses in the same position for a longer time,

rather than transferring to a higher paying job. This will save the institution money.

Encouraging Leadership through Certification

C. Baker encourages all nurses to become certified and states certification is actually part

of the clinical advancement ladder (personal communication, October 21, 2010). Ellis and

Hartley (2009), state that certification is an indication of competence and suggest a positive

relationship between certified nurses and patient outcomes. To achieve certification in any

specialty multiple measures must be achieved which ensures competence in that area (Ellis &

Hartley, 2009). C4 has study books, practice tests and peer support for certification and the

hospital reimburses the nurse for the cost of the test upon successful completion (C. Baker,


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Certification effect on staff, patients and institution. Many nurses have a goal of

becoming certified because we have peer groups that talk about certification and encourage it (C.

Baker, personal communication, October 21, 2010). Once a nurse becomes certified, he/she gets

OCN (Oncology certified nurse) on their identification badge and a plaque on the wall with their

name on it (personal communication, October 21, 2010). Patients see the plaques and mention

that it instills confidence in the nursing staff on the unit (C. Baker, personal communication,

October 21, 2010). The institution benefits by providing higher quality care and being approved

by accrediting agencies (C. Baker, personal communication, October 21, 2010).

Encouraging Leadership through Peer Review

The unit participated in a hospital-wide initiative for professional goal development to

determine if clinical coaching, used as a form of peer review, has a positive impact on clinical

practice, professional development, professional engagement, and patient outcomes (C. Baker,

personal communication, October 21, 2010). According to Ellis & Hartley (2009), appraisal is a

formal process of reviewing an individual against established standards. The American Nurses’

Credentialing Center (2008) “Describe and demonstrate that nurses at all levels routinely use

self-appraisal, performance review, and peer review, including annual goal setting, for the

assurance of competence and professional development”.

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Peer Review Effect on Staff and Institution. The results for the staff from this

initiative were: positive affirmations and team cohesiveness (Fisher, Waycaster & Weaver,

2010). Some positive comments from staff were that less experienced nurses received support,

and everyone became more goal-oriented and aware of educational opportunities (Fisher et al.

2010). Management noticed that more people were motivated to participate in unit based shared

governance and provide encouragement to peers (Fisher et al. 2010). The overall outcome from

the initiative was that nurses’ perceptions of professional development improved significantly in

the coaching group (Fisher et al. 2010).

The impact on the institution is that the study group recognizes that it needs to engage

clinical coaching in leadership groups and that further research is needed on other

units/organizations (Fisher et al. 2010). The ultimate goal being a published research article and

continued improvement in support for clinical coaching as a form of peer review (Fisheret al.

2010).

Decision Making or Problem Solving Process

Analyzing and making decisions on the unit is a daily occurrence that often can be

uncomfortable, it is imperative to take time and understand all sides of an issue before jumping

to conclusions (C. Baker, personal communication, October 21, 2010). Involving staff in

decisions such as hiring, environmental changes and unit processes will take the sole ownership

off the manager creating a sense of community in the department (Ellis & Hartley, 2009). C.

Baker states that her unit does this through staff meetings quarterly and with newsletters when

things come up in between, daily huddles and annual discussions (personal communication,

October 21, 2010). The unit also has a shared governance group that meets regarding unit

processes (C. Baker, personal communication, October 21, 2010).

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Daily Communication

The unit has started a practice called the “huddle” which allows all members of a shift to

meet for ten minutes at the beginning of their shift to coordinate patient care issues and to

disseminate all of the daily communication issues and changes (C. Baker, personal

communication, October 21, 2010). The charge nurse or manager run the discussion, all of the

information is kept in a log on the unit, and the staff is expected to read and be responsible for

the information (C. Baker, personal communication, October 21, 2010).

Huddle Effect on Staff, Patients and Institution. The daily huddles bring more team

cohesiveness among the staff allowing them to work together toward a goal (C. Baker, personal

communication, October 21, 2010). The huddle also allows for better continuity of care for our

patients (C. Baker, personal communication, October 21, 2010).

Annual Discussion

C. Baker is currently meeting with all staff one on one for annual discussions (personal

communication, October 21, 2010). The evaluation is performed with clear criteria and a

checklist of staff performance (C. Baker, personal communication, October 21, 2010). The staff

is given a sheet to fill out prior to discussion that includes this year’s accomplishments, goals for

the next twelve months, and an area that they can discuss any issues they choose (C. Baker,


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Annual Discussion Effect on Staff, Patients and Institution. According to Ellis and

Hartley (2009), an effective performance appraisal improves the functioning of the organization,

fosters personal development of the employee, and follows clear criteria. Performance appraisal

allows for open communication regarding goals and recognition for accomplishments (Ellis &

Hartley, 2009). Receiving recognition motivates an employee to continue working hard, which

benefits staff, patients and the institution (Ellis & Hartley, 2009).

Management of Conflict

According to Ellis and Hartley (2009), conflict is dissension occurring when two or more

peoples view things differently. The most effective way to deal with conflict is through

negotiation and mediation (Ellis & Hartley, 2009). Negotiation, according to Ellis and Hartley

(2009), is conferring with another to resolve an issue. Mediation is intervention between two

parties to resolve an issue (Ellis & Hartley, 2009).

Conflict among Staff

C. Baker feels that certain situations should not be tolerated in the workplace such as

feeling unsafe, bullying and anger (personal communication, October 21, 2010). Staff

understands that any type of disagreement needs to be discussed away from patients (C. Baker,

personal communication, October 21, 2010). C. Baker follows the rules of assessing the

situation before reacting to it by trying to gather as much information as possible before

confronting (personal communication, October 21, 2010). C. Baker encourages staff to attempt

to communicate with each other but offers mediation as necessary and corrective discipline as

required (personal communication, October 21, 2010). Ellis and Hartley (2009) support this

management style with their definition of behaviors for confrontation, which are assessing the

situation prior to confrontation, conducting the confrontation in private to prevent embarrassment

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and showing the other party respect (Ellis & Hartley, 2009).

For severe conflict, issues there are steps that must be followed to terminate the employee

(C. Baker, personal communication, October 21, 2010). The steps are defined in a Corrective

Action Policy, which requires two counseling notes, one written warning and then termination

(C. Baker, personal communication, October 21, 2010). Careful documentation must be done

when performing corrective action to prevent litigation (Ellis & Hartley, 2009).

Effect of management of conflict on staff and patients. Employees know that conflict

is not tolerated, which lends itself to a more cohesive and peaceful work environment (C. Baker,


As a Participant or Interpreter of Research

In addition to the clinical coaching for peer review, as mentioned in the Encouraging

Leadership Through Peer Review section of this paper, evidence-based practice was used to

discontinue the neutropenic diet on C4 (C. Baker, personal communication, October 21, 2010).

In an effort to implement the use of evidence-based practices into our oncology center, a

committee of nursing staff formed to review the literature (C. Baker, personal communication,

October 21, 2010). The literature review of evidenced based articles stated the diet was not

effective in preventing infections in the immune-compromised patients therefore it was

discontinued (C. Baker, personal communication, October 21, 2010).

Effect on Patients, Staff and Institution

Since the implementation of the non-neutropenic diet, standard monitoring of monthly

infection rates continues, with no change noted (C. Baker, personal communication, October 21,

2010). Patient satisfaction regarding meal choices has increased and staff feedback regarding

implementation of the change has remained positive (C. Baker, personal communication,

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October 21, 2010). It has not been a full year so results are yet to be tallied but similar results

were found in the research (C. Baker, personal communication, October 21, 2010). Tarr and

Allen (2009), support Ms. Baker’s statement in their results of patient satisfaction with meals

going from 42.9% to a high of 75%.

Conclusion

The project allowed me to analyze the challenges of being a nurse leader/manager.

Management affects staff, patients and the organization. Further research is needed before I take

a management position, but this process has shown me the skills needed to do so.

References

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