By Jennifer Thew, RN
This article first appeared in the January/February 2018 issue of HealthLeaders magazine.
Many healthcare organizations expect nurse managers to have 24/7 responsibility for their nursing units.
Additionally, managers are increasingly overseeing more than one unit, resulting in large numbers of direct reports.
But is it realistic to place an enormous scope of responsibility on nurse managers and expect them to succeed?
Cheryl Hoying, RN, PhD, NEA-BC, FACHE, FAAN, senior vice president of patient services at Cincinnati Children's Hospital Medical Center, asked herself that about seven years ago; her answer was no.
Hoying came to this conclusion after noticing two concerning trends among her staff.
"I was seeing all the directors getting out of here at 7 or 8 o'clock at night and not being able to get home in a timely manner," she says. "And we were hiring from the outside for every nurse manager position that came along."
As a result, Hoying implemented changes to create a more reasonable scope of responsibility and make the positions in nursing management more appealing.
Here's what she did.
Created a manager-to-FTE ratio
To address the issue of work overload, Cincinnati Children's established a 1:25 ratio of managers to FTEs. To achieve this ratio, Hoying first had to create nurse manager roles to support the medical center's nursing directors.
"I approached the CEO at the time and said, 'Jim, I need $1 million,' " she says. "He said, 'What for?' I said, 'I want to put in managers for the directors.' "
Hoying got her request. The additional managerial staff was allocated to units based on the unit's number of employees.
For example, a unit with 50 FTEs had one nurse director and then received an additional nurse manager. A unit with 75 FTEs had one director and received two additional nurse managers.
"I think by that ratio, you're able to connect with the staff and provide the mentoring with the staff that's needed," Hoying says. "It allows the manager to be successful and be the nurse leader that that individual can be."
Assigned managers to off-shifts
Role overload was the most important predictor of nurse manager stress, found this November 2013 study. Other factors were organizational constraints and role conflict.
The addition of nurse managers also allowed the organization to provide support to staff working off-shifts.
"When you think about it, after 7 o'clock, how much management do you have in an organization? Usually it's just a nursing supervisor," she says.
This extended management coverage also helped meet the workplace preferences of millennial nurses.
"With millennials especially, when they ask a question, they expect an answer pretty quick," Hoying says. "By having those managers there, they're able to help problem solve and observe the clinical practice of folks. That was kind of a criticism before. How could you evaluate my practice if you weren't there to observe?"
Developed a management pipeline
Directors can now dedicate time to coaching the nurse managers on essential skills, such as HR issues, how to analyze a budget, and understanding overtime variations.
"The difference, for me, is that having that kind of setup lets them learn as they go. And they have 25 employees that they're helping along," she says. "Otherwise, the expectations that they put on themselves are just tremendous. It's just like a new staff nurse: You just begin to know what you don't know after a year."
In addition to director-manager mentoring, Cincinnati Children's offers internal leadership development programs, including four structured courses:
- Bedside leader—This course is for nurses who wish to implement their leadership skills at the bedside by expanding their leadership capabilities to improve patient care and outcomes. Participants are introduced to the concepts of leadership behavior and systems thinking and cover topics such as healthcare economics, finance, data application, and fostering healthy work environments.
- Emerging leader—This program is designed to facilitate leadership development succession planning by developing a pool of bedside nurses who display clinical excellence and have an interest in professional advancement. It includes online and didactic learning opportunities, mentoring by hospital leaders, and coaching by the leadership development team. Topics covered include leadership and professional development, measuring excellence, finance, staffing and rounding, informatics, and safety.
- New manager—This course is aimed at strengthening the confidence and managerial skills frontline managers need to excel in their roles. It encompasses managerial competencies from AONE, the Advisory Board, Magnet®, and organizational core values. Additionally, there is individualized professional coaching and mentoring to help new managers apply these concepts to the real-world work environment. Topics covered include strategic thinking, measuring excellence, human resources, and finance and staffing.
- Experienced leader—This track allows experienced leaders to participate in in-depth analysis and discussion of issues they face in their roles. Topics include mindfulness in nursing care, strategic thinking, healthcare legislation, informatics trends, labor laws, and nursing research.
"What we incorporate into our programs is the science and the art of nursing, because we feel it is a solid foundation professionally," Hoying says. "So it's creating the leader within yourself and coaching others."
Hoying also sends one nurse manager a year to the American Organization of Nurse Executives' (AONE) nurse manager fellowship program.
"What I want to happen is for them to meet 29 other colleagues from across the country that they can call up and brainstorm with," she says. "I think having formal programs like that is just so valuable because it gets people out of the realm of just seeing things one way and that's how their hospital does it. It gives them the chance to look at the 29 other ways to do things and to make sure that they're hearing various perspectives."
Hoying has sought feedback from targeted conversations with nursing directors and managers, and they have reported positive changes in their workload. Feedback was collected through email, interviews, and conversations.
In qualitative statements during these conversations, nurses reported increased managerial coverage on the off-shifts, and directors and managers said they fielded fewer calls in their off-hours, particularly during the evening.
Directors reported being able to delegate items to their managers for follow-up rather than staying to resolve issues themselves.
They also reported having the time for strategic planning, networking, process improvement, education, and mentoring. One-to-one time with direct reports has also increased, and onboarding and communication with new staff members has improved.
"The mentorship between directors and nurse managers has been wonderful," Hoying says. "When a director position came open recently, seven managers applied for it."
Indeed, applications for nurse manager and director positions have risen. In 2010, there were 19 overall applicant submissions for manager and director positions in the patient services department. In 2011, the numbers rose to 179 applicants for 16 positions. In 2016, there were 240 applicants for 31 positions.
"We have been able to fill these open positions internally rather than seeking these candidates from the outside," Hoying says.
The manager-to-FTE ratio has helped free up time for managers and directors to pursue internal and external professional development opportunities.
"We build in [time] for the director to help mentor and coach the nursing group that's coming up in the ranks," Hoying says.
Since 2008, the organization has had one participant in the Executive Fellowship in Innovation Health Leadership offered by AONE and Arizona State University; two participants in the AONE Nurse Director fellowship; 11 participants in the AONE Nurse Manager Fellowship, and two participants in the AONE Healthcare Finance for Nurse Executives Certificate Program.
"As the CNO, it is my responsibility to make sure the right resources are provided to enable the unit leadership to be successful and enjoy their role. If not, and that role turns over, it affects everybody on the unit," says Hoying.