Unbearably Unhappy, Cont’d [Updated]

Wade Schuette at Perspectives in Public Health submitted a lengthy and thought-provoking comment on my post  a few days ago about bad nurse-managers. He suggests the issue, by default, needs to be addressed through professional organizations like (in Ontario) RNAO or nationally, CNA, or in the United States, ANA. He wrote:

I’d say it’s more than an “indicator of poor patient outcomes” … it’s a direct cause.

It’s fascinating, in a morbid way, that a unit with a leak in the ceiling and wet floor would be cited by JCAHO as a patient risk,  but a unit with a manager who clearly damages the psychological-safety and open feedback teamwork required to catch errors and deliver safe care is allowed to continue without comment.

[snip]

So, assembling the fragments of thought here, it would seem that (1) nurses (or anyone) could substantially improve patient care if they could take effective action that would remove rattlesnakes, wet floors, and dangerous managers from the system.
(2) For anyone to try this alone, unaided, by pushing UPWARDS is a proven no-win approach.
(3) Don Berwick is the right guy to lead an effort to put teeth in a move to deal with such managers, and CMS certainly has the clout to threaten to cut off all medicare funding for a hospital that refuses to listen. So that part is in place, finally.
(4) So how can individual nurses contribute to this nascent action coming to fruition. Probably, that’s what professional organizations are about and for.

Conclusion — it’s within nurse’s professional duty to lean on and assist their collective professional organizations to put pressure on Berwick to “do the right thing”, and to rally other nurses to join them in this move to improve patient care AND, as a side effect, to improve working conditions, retention, cost-effective care, hospital survival, etc.

Is that logic solid?

I would agree, with the important caveat of recognizing the limitations of professional organizations. (And incidentally, I wonder if he would include unions in that group of professional associations?) They move glacially, think globally not specifically, and if they are anything like the RNAO, they tend to be somewhat a reflection — unintentionally, I’m sure — of the nursing “leadership”, i.e. managers, educators and such, not front line workers. At the end of it, I fear, the poor nurses I wrote about would only be helped only in a very indirect way, which is to say in the short or even medium-term , practically not at all.

from RNAO's The Healthy Work Environments Best Practice Guidelines

However, there is one particular way organizations like RNAO (and its provincial/state/national counterparts) can be useful: in the development of best practice guidelines. The RNAO, for example, has developed The Healthy Work Environments Best Practice Guidelines, an enormously useful document which addresses this very issue: what is best practice for nurse-managers?

From our review of the literature [writes the RNAO], we identified the following transformational leadership practices that result in healthy outcomes for nurses,
patients/clients, organizations and systems:
1  building relationships and trust;
2  creating an empowering work environment;
3  creating an environment that supports knowledge development and integration;
4  leading and sustaining change; and
5  balancing competing values and priorities and demands.

But again, these are best practice guidelines: evidently the experiences of the nurse on the floor varies widely according to institutional culture and values. I suspect in places where the contribution of  nurses is minimized or demeaned, best practice of any sort would be thrown out the window.

Another thought: it is never clear to me how nurses moving into managerial positions somehow forget they are nurses, and are still subject to standards maintaining patient care and safety (to return to Wade Shuette’s point),  and bad management pretty well precludes providing it: I mean, from a strictly regulatory point of view, becoming a nurse manager does not (or rather, should not) absolve from making decisions that adversely affect patient care, and hospital policy or the priorities of the human resources department does not automatically over-ride professional obligations. Should nurse managers be held professionally accountable for their managerial style when they create poor work environments? Absolutely. However, I have yet to see any nurse manager be formally disciplined by my own professional body, the College of Nurses of Ontario, for poor management. As long the CNO (and its equivalents in U.S. state nursing boards) essentially see themselves as extensions of the management disciplinary process, this is not likely to happen.

I think the best answer, in the end, is as another commenter wrote

we must vote with our feet. Speak our truth politely and respectfully, for our own good, i.e., the knowledge that we’ve spoken and not suffered in silence before slinking away, and then seek out healthy work environments. Not to do this would be hypocritical; we are about health promotion, and need to live and practice what we teach.

It is important to recognize that nurses are not responsible for sick environments and cannot “fix” the negative energy around them. We can speak, and offer to be part of the solution, but there are those who would turn the problem back on the victims, and many nurses, ever eager to help and to be team players, might embrace a problem that is not rightly theirs. A manager who exudes negative energy, and a toxic work setting, are that way for a reason, which others may or may not ever understand. But what it sure is that they are not as they are solely for want of our magic fixes, and we are not likely to save the day with heroic efforts to “help” the leopard change its spots.

Walk, my colleagues! You and your patients deserve better!

Excellent, and I couldn’t agree more. And it has the added benefit of causing real pain to a health care corporation. Bad management has immediate monetary consequences. Filling vacancies, and then hiring and training new nurses is not without real costs: I have heard figures of upwards to $50K per nurse for orientation, incentives, and lost productivity. Enough losses of this sort (one would hope) should be enough to twig someone higher up something is amiss. I know, in practical terms, this is not realistic for many older nurses, who are unwilling to give up seniority, benefits and pension. They have too much invested in their present employer to leave, and I know some managers willingly, even enthusiastically, exploit and abuse this commitment. Younger nurses, and especially new(ish) graduates have far more flexibility, especially if they work in large urban centres like Toronto which have a multiplicity of employment choices.

[UPDATE: Apparent cat-induced post title malfunction corrected. The cat has been spoken to, sternly. The cat apparently doesn’t care. She writes: djpofsaha’of;alllllllllllllllllllguuuuuuuuujf’ashf. So there.]

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  1. #1 by Joni Watson on Monday 30 August 2010 - 1445

    Great post. Definitely agree with commentors. I’ve been privileged to work with some most fabulous nurse managers in my short, six-year nursing tenure to date. However, I have seen the effects of poor nurse managers.

    From my perspective, I also think nurses, in general, are ill-prepared to become nurse managers. Yes, baccalaureate prepared nurses (in the US) have some management classes (1 or 2, if they’re lucky), but that’s not near enough. Nurses need *real* business classes – from schools of business within universities. I have an MSN (with an emphasis in nursing administration) and an MBA via a dual track program. The MSN is great, but it’s the MBA that I have found has taken my management and leadership to a completely different level than what I learned in undergrad or graduate nursing school (i.e. organizational behavior, operations management, finance, business planning, human resources management, etc.)

    We need more nurse managers (not just CNO’s or DON’s) with business degrees, or at least substantial business education, leading and managing nurses.

  1. Response to “Dark times” | Not Nurse Ratched

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