Dawson, Carrie BSN, RN; Aebersold, Michelle MSBA, RN; Mamolen, Nancy MSN, RN; Goldberg, Janet MSA, RN; Frank, Cathy BA
The most critical imperatives facing hospitals today fall squarely within the scope of nursing unit leaders' core responsibilities. Providing high-quality patient care amid increasing public concern, retaining staff in the face of intense labor shortages, and meeting rising patient demand with shrinking budgets are among the challenges nurse managers face daily. With the nursing shortage only worsening, it is critical that frontline managers be well-leveraged in the effort to recruit and retain staff.1
Since the early 1990s, healthcare organizations have undergone multiple transformations such as downsizing, primarily because of budget reductions necessitated by the influence of managed care and changes in federal reimbursement. Often the primary targets were nursing services within these organizations. The University of Michigan Health System (UMHS) has been no exception to this process.
At the UMHS, reductions were implemented in a number of ways. Examples include replacing assistant head nurse (AHN) positions with administrative assistant roles. Turnover in nurse manager positions created cost-effective opportunities to combine units, rather than hire other managers. Some inpatient units were aligned with outpatient clinics giving managers both inpatient and outpatient responsibilities. Staff positions were periodically frozen and filling positions required multiple approvals. For nurse managers, coaching and mentoring staff was viewed as a core responsibility and highly valued; however, with increasing span of control and responsibilities, managers were challenged to prioritize this work in their practice.
By 2001, an analysis of institutional metrics revealed that these downsizing strategies had negatively impacted employee satisfaction and the quality of nursing care delivered. The University of Michigan Health System is a large academic tertiary healthcare organization employing approximately 3000 registered nurses. The nurses are represented by the University of Michigan Professional Nurse Council (UMPNC) and the Michigan Nurses Association. Transforming nursing at Michigan to address these challenges required a multifaceted approach. To begin with, a management redesign team was created and charged with designing recommendations for a model of infrastructure support for the nurse managers. Other efforts to transform nursing at the UMHS included creating a retention team and a nursing recruitment department.
The UMHS nursing leadership felt strongly that the work of redesigning the nursing management infrastructure should come from those who are closest to the work. This involved creating a team of nurse managers to research the literature, understand current models, and design and implement new nurse management infrastructure model(s). The specific charge to the team was as follows: to review the existing literature and benchmarking data on management structures to create an effective model of ongoing support for the clinical nurse managers of the inpatient units/areas within the nursing services budget.
The team convened included managers representing a range in the span of control from small to large. Small was defined as a manager over one 28- to 32-bed unit with an average of 35 full-time equivalents (FTEs). Large was defined as 1 manager over 3 or more patient care areas with as many as 150 FTEs. Other members included a director of nursing, a nurse manager from the central staffing resource pool, and a representative from the University of Michigan School of Nursing. An organizational effectiveness consultant was invited to facilitate the team process. An intern from the department of program and operations engineering was assigned to the group to facilitate any data management. One member of the team was appointed as project leader for the work.
Work began by familiarizing the team with what was happening across the country, particularly in organizations similar to ours. A literature search and benchmarking with other institutions was undertaken to understand current models and support roles. One purpose of the benchmarking was to evaluate and compare the manager-staff ratios. More important, however, benchmarking provided an opportunity to seek out innovation and creativity. Who was trying something new and was it effective?
Our findings led us to the research conducted by the Advisory Board Company captured in Elevating Frontline Leadership.1 Much of their work was utilized in the redesign process. In conversations with other organizations, it was found that many were beginning to ask similar questions. Many were reevaluating current models or had completed a redesign effort. Some strategies identified were a return to reducing the number of units per nurse manager, incorporating an AHN or similar role, and/or providing off-shift coverage and central bed management.
To gain an understanding of the issues nurse managers were experiencing, highly structured focus groups were designed and conducted to capture the “voice” of every manager. The nurse manager team at the UMHS is a very experienced group of individuals, with an average of 7 to 15 years of managerial experience. Together they have weathered the many changes in healthcare, including the increasing span of control for this role.
In addition to nurse manager focus groups, focus group sessions were held for staff nurses, advanced practice nurses, unit administrative and clerical staff, and nursing directors. Physicians were also surveyed regarding their view of the nurse manager's role. Questions posed to the participants were designed to elicit an understanding of each participant's needs, expectations, and perceptions of the ideal role of the nurse manager.
These data elements would be later compared to a time study that was conducted to gain insights into how managers actually spend their time. Data from the focus groups were collated and reviewed for alignment or gaps in perceptions and needs across similar types of job roles. Fundamentally, the issue was seeking to understand if the needs and expectations of these key stakeholders were in alignment with the nurse managers' needs and expectations.
Findings from these focus groups indicated that responses from nurse managers, directors, and physicians regarding the ideal role of the nurse manager were strongly aligned. The most prevalent theme in the responses was that the role of the nurse manager was to ensure quality patient care, although the physicians articulated it as “setting standards of care.” The second most articulated theme was “provide leadership,” followed by “coaching and mentoring staff.” Other highly rated aspects of the role included “communicating,” “problem solving,” and “planning and collaborating with others.”
Clinical nurses stated that they most depend on the nurse managers to provide the resources, both human and material, to do their jobs. They also stated that they depend on the nurse managers to provide vision, leadership, visibility on the unit, to be the go-to person on the unit for clinical and personnel information, communicate vital information, resolve conflict, and advocate for nursing interests. It was found that administrative and clerical staff interests were similarly aligned to the clinical nurse groups.
One last important data element remained to be evaluated, understanding what currently consumed the nurse manager's time. A time study was conducted in July 2001. The time study was modeled after the nurse manager time audit from the Advisory Board Company.1 Twenty-three nurse managers, across the inpatient units, carried a random beeper for 1 week. The pager was carried during the hours of 6 AM to 7 PM, Monday through Friday. The pager was randomized to beep 16 different times. Each time the pager went off, the nurse manager logged onto what they were doing at the time.
At the conclusion of the study, data from each nurse manager were collated. Nurse managers were also surveyed to describe the ideal amount of time they would like to dedicate to each management function. Actual time spent was compared with ideal time spent. It was found that nurse managers spent about 50% of their time doing staffing/scheduling, office work, and institutional activities; however, in the ideal survey, managers indicated they wanted to spend only 18% of their time on these activities.
Moreover, the survey on ideal time revealed that they wanted to spend at least 36% of their time, coaching and mentoring, budgeting, and providing support to their staff, but currently they spend only 14% of their time on these activities. The largest gaps in ideal versus actual time spent were in staffing and scheduling, institutional work, and staff support. When compared to the Advisory Board Company1 study conducted nationally, managers spent more time in daily operations and hospital responsibilities (66% vs 36%). The final conclusions demonstrated a gap in ideal versus actual time spent. This was important because staff in the focus groups responded to what they needed from their nurse managers (time coaching and mentoring and staff support activities).
The findings from all sources of data including the focus groups, benchmarking, and time study were presented to the nursing leadership. During the presentation, managers, directors, and clinical nurse specialists were provided with an interactive means of posing questions and dialoguing about the results and next steps.
Integration of Data Elements
Our next challenge was to create a common view of the ideal role of the nurse manager, integrating all these data elements. Members of the redesign team believed that creating a shared understanding of the ideal role would dramatically impact our ability to achieve our nursing vision. Two off-site workdays were held to develop the framework for this transformation and ensure alignment with our nursing vision and values.
The first step at the initial workday was to create a common understanding of the current work of the nurse manager. Specific tasks and responsibilities that had migrated to the nurse managers over several years of budget reductions were identified. The team sorted out what we believed should continue to reside as the nurse managers' responsibility and what could be delegated or eliminated if hospital systems were improved. Key areas were identified that would need to change or improve if we were to implement the ideal role of the nurse manager (Figure 1).
Through integration of data, understanding current work and needs, and a shared vision, the team came to consensus on the 4 key elements of the ideal nurse manager role: (1) ensure quality patient care, (2) provide leadership, (3) coach and mentor staff, and (4) manage operations. Each of these key elements was further developed to include goal statements and metrics (Table 1).
Results of Analysis
Two prominent themes had emerged from the results of the work. The first was the need for clinical infrastructure support and the second was administrative/operations infrastructure support. The infrastructure team broke into 2 subgroups to further develop these 2 themes. Additional staff was added to the subgroups to ensure appropriate expertise for the design phases.
The clinical infrastructure subgroup included a director of nursing, nurse managers, an educational specialist, a clinical nurse specialist, and a nurse practitioner. The team wanted to capture the concept of flexibility in a model. The model needed to recognize that inpatient units are dynamic and constantly changing relative to patient populations and acuity, staffing patterns, staff workload, and staff turnover affecting seniority and experience of remaining staff. The model needed to allow for the diversity of staff demographics and patient populations among each of the units. Last, the model needed to be flexible as these elements change over time. A cafeteria-style menu was created to provide the nurse manager with options for clinical support positions within the organizations' current clinical ladder.
The clinical side of the Michigan Leadership Model has a basic architectural design similar to Maslow's Hierarchy of Needs (Figure 2).2 The key advantage of the clinical side of the Michigan Leadership Model is the provision and utilization of a variety of roles, which correlate with the needs of the unit staff and flex as the staff develop and mature over time. The main triangle or building block of the model represents a staff nurse role, with basic entry-level orientation and competencies being the foundation of the triangle. Over time, as nurses solidify their skills, they move up the triangle in areas that represent clinical advancement along a developmental pattern.
This progression includes passage through phases of ongoing competence, novice to expert clinical practice,3 emerging clinical leadership, increased programmatic responsibilities, and serving as a change agent and/or resource to others. It ends at the peak of the triangle with the staff nurse as an “expert.” The adjacent and inverted triangles that surround the basic staff nurse triangle reflect the positions that provide educational and clinical leadership support to the staff nurse as they mature over time.
These clinical roles are defined as the general standard in the clinical ladder for nursing at UMHS; however, they are utilized in an adaptable fashion depending on the staffing needs at the individual and nursing unit levels. The clinical nurse II (CNII) and educational nurse coordinator roles are generally responsible for coordinating and providing the basic perception for new nurse orientation. The Clinical Nurse III (CNIII) and Clinical Nurse IV (CNIV) roles function in more specialized roles, and yet, can flex to provide support as needed. The inverted characteristic of the CNIII and CNIV triangles reflects this flexibility to swing down and cover basic education at the wider base of the staff nurse triangle. In contrast, the wider base of the CNIII and CNIV triangle depicts the correlation of their work with the advanced learning needs of experienced staff who demonstrate critical thinking skills and a readiness for professional advancement in areas such as research and publishing.
This subgroup was charged with identifying additional support to be focused on administrative and operational support for the nurse manager. The subgroup was composed of nurse managers, administrative assistants, a permanent charge nurse, and a CNIII. The group again used a cafeteria-style approach and designed a list of options a nurse manager could select from. The choices included a payroll clerk, secretary, administrative assistant I (AAI), administrative assistant II (AAII), clinical nurse supervisor, and CNIII.
Among the options listed in this menu, redesign changes were made in the following roles by the infrastructure team. The first addition to the menu was an AAII position that was fashioned after the operations coordinator position created by Massachusetts General Hospital and highlighted in the Advisory Board Company literature.1 Along with AAI responsibilities such as scheduling, payroll, secretarial, and personnel paperwork support, the redesigned AAII position carries additional budgetary responsibilities and supervision of nonclinical staff such as unit clerks.
This would provide additional support to the nurse manager with larger spans of control to reduce the manager-staff ratio. The clinical nurse supervisor role, similar to the AHN position, was eliminated during the organization's downsizing efforts in the 1990s. To immediately reduce the workload of the nurse manager with a large span of control, interim clinical nurse supervisors were placed in 6 areas, while the infrastructure redesign team simultaneously completed its work. The team took this opportunity to evaluate this role and redesigned it to align with the support needed by managers and staff.
The CNIII role was traditionally designed to function as a clinical expert and program coordinator for the care of specific patient populations. These positions were budgeted to provide 80% direct patient care; the remaining time was for nondirect patient care activities such as developing patient education materials or critical pathways. In some areas, the role expanded to function as an operational lead for daily unit functions. Sometimes budgeted or operationalized at 100% nondirect care, this role supports the unit charge nurse, actively participates in unit committees, and completes staffing and scheduling functions for the unit. They are expected to serve as a role model for staff and coach/counsel staff as appropriate.
As members of UMPNC, they cannot hire or discipline staff, but the Michigan Leadership Model could be used to provide additional support to a nurse manager who has multiple units or to provide off-shift support to units. This administrative infrastructure of the Michigan Leadership Model provides the operational support needed to run the unit. The roles of clinical nurse supervisor and CNIII in this portion of the model would be expected to flex their time between staffing support and administrative support, depending on the needs of the unit.
Following completion of the clinical and operations subgroups, the framework of the infrastructure model was formed. It is based on the principles/assumptions outlined in Figure 3. There are 2 key concepts to the model. The first is the notion of supporting or leading a unit with a “triad,” similar to the concept embraced by Massachusetts General and highlighted in the Advisory Board.1 Titled the Michigan Leadership Model, the model includes the triad of nurse manager as leader, and roles for clinical support and administrative support (Figure 4).
The second unique characteristic in this model is a cafeteria or menu style of positions to choose from to support the clinical or the administrative components of the model. Patient care units are dynamic and diverse in span of control and variable in needs depending on the demographics of staff. This creates huge variability in the workload for the individual clinical nurse manager, thus necessitating more than one type of support position to choose from.
Tools for Managers
The assessment matrix is a tool designed by the team to assess the span of control or scope of work. The information gathered in the assessment was used to determine the clinical and administrative positions necessary to support the staff and work aligned with a nurse manager. This model recognizes the dynamic status of managing staff and work associated with running a unit therefore drawing on multiple metrics in addition to a number of FTEs to quantify the span of control. Historically, for UMHS, FTEs, a static number, was the only indicator used to determine the amount of support a nurse manager would need to run one or more units.
The metrics were developed after review of the work done by the Advisory Board and evaluating the results of our own time study. Key items from the Advisory Board in evaluating span of control were (1) the experience of the nurse manager; (2) strength and stability of staff that encompassed staff nurse years of experience; (3) morale/turnover and independence; (4) the current level of manager support existing; (5) cooperation of ancillary department; (6) physician support or lack of; and (7) support from senior leadership.1
As scope of responsibility within our own organization was reviewed, 3 distinct levels of responsibility were used as the framework. For example, a nurse manager with a span of control of 2 inpatient units and a clinic was designated as level 3. A nurse manager with 1 very large unit or 2 smaller units was designated as a level 2, and a manager with an average size single unit was a level 1. Each level, 1, 2, and 3, had increasing scope of responsibilities as measured by FTEs, number of units, and programmatic responsibilities associated with those areas. The program responsibilities were defined as administration functions required for entire programs such as our trauma program or the congenital heart center.
To capture the dynamic work associated with these levels, the following metrics were developed and finalized (Table 2): percent turnover, the number of staff supervised, patient population, intensity/acuity of patients, geographic location, skill mix of staff, and demographics of staff. Administrative indicators included programmatic work, multiple budgets, and multiple units.
Nurse managers independently evaluated the work of their units using each indicator. For example, the average number of hires per year for 1 nurse manager's area may be 1 to 10, receiving a level 1 score.1 The next indicator, number of staff (in bodies, not FTEs), may be 76 to 125, scoring at level 2 for that indicator,2 and so on. Scores were totaled and divided by the number of indicators. Total scores could range from 1 to 3. This score corresponded with a recommended level of support staff, outlined in a staff support grid created by the team. The support staff grid, recommended by the team, was developed on the basis of the findings of this redesign effort.
The final assessment matrix (Table 3) with associated levels was tested by scoring each of the units at the UMHS seeking to verify if the largest span of control actually scored a 3. Another check was to compare units of equal size but differences in another variable, such as one with stable staffing, the other with high turnover. The scores should be different. Lastly, the team independently worked with nurse managers asking them to score themselves.
Following completion of the model and assessment tools, the next step was to seek endorsement from the nursing directors through a presentation/educational process. This was the first in a series of challenging meetings where the team responded to questions and provided rationale for assumptions built into the model and its supporting framework. With this endorsement, it was agreed to roll out the process to the unit managers with some minor modifications. The interim chief nurse officer wanted the process to be open and encourage innovative thinking on the part of the managers. To avoid being influenced by a predetermined number and type of resource based on an assessment score, the support staff grid was removed from the materials that would be presented.
Nurse managers were asked to be mindful that their ideas link to the following principles:
* Variable models;
* Share/pool resources;,
* Develop a model, including the staff at the point of service;
* Keep the representation of peers at the front;
* Think functions not structure, including what to stop doing;
* All roles should be reviewed; and
* Aim for a budget neutral outcome.
The team was encouraged to, retrospectively, compare the nurse manager priorities against what the support staff grid would have recommended to assess the validity of the tool for its potential to be used in the future for additional requests.
Education and Implementation
Rolling out the process to the nurse managers began with an educational presentation, including discussion and question-and-answer session. Packets with information on how to use the toolkit were provided; additionally, the PowerPoint presentation and tool documents were made available online. Each individual nurse manager was expected to complete an evaluation tool, created by the team to record preimplementation metrics and the assessment matrix. The team created an infrastructure analysis tool for nurse managers and nursing directors to record findings from the matrix and identified support roles needed.
Nurse managers met with their respective nursing directors to review data and assessed needs and prioritized the needs identified. In addition to developing their own unit strategies, it was expected that nurse managers reporting to the same nursing director explore opportunities to share resources across units. If colleagues did not report to the same director but could identify ways to share resources across units or areas, these ideas should be considered to maximize the amount of support that could be developed from a limited pool of dollars.
Finally, in an effort to promote creativity and shared thinking, the infrastructure team set up 2 support sessions for the nurse managers. The intent was to provide an atmosphere where managers might benefit from hearing different approaches or strategies as to how to think about administrative and clinical support structures.
Following completion of the infrastructure analysis and ranking of priorities, the nursing directors came together for a series of weekly meetings over the course of a month. In these meetings, nursing directors presented the recommended priorities for their respective areas. As a group, the nursing directors developed a process to fund as many infrastructure priorities within the allotted resources. This step in the process was complex and a critical step toward bridging the work of the infrastructure team, with outcomes that responded to the interests of the nurse managers.
Over the past 2 years, the inpatient units that received additional infrastructure support have demonstrated an improvement in their ability to recruit, hire, and retain new staff. In addition, several nurse managers have been able to demonstrate a need and received support roles such as a CNIII or clinical nurse supervisor. Recruitment and retention efforts on the units have been aided by these new support roles, and nurse managers have expressed satisfaction with the clinical nurse supervisor positions.
Currently, data such as those on employee and patient satisfaction, clinical indicators, and turnover are being analyzed to quantify the impact of implementing the Michigan Leadership Model infrastructure. In addition, a return-on-investment analysis will need to be conducted. Following the implementation of the infrastructure roles, nursing leadership continues to assess for opportunities to improve the utilization of advanced clinical practice roles at the unit level to further the development of the professional bedside practitioner.
© 2005 Lippincott Williams & Wilkins, Inc.