A POLICEMAN is in the lobby responding to a 911 call from a patient, stating that he is being held in the hospital against his will. An intensive care unit nurse calls because she has critical laboratory results, and the physician has not returned her urgent phone calls. The nurses from the surgical unit report an increasingly strong smell of smoke on the unit. There is a discrepancy in the narcotic count on the oncology unit. A new nurse asks for help with an abdominal drain.
These are just some of the situations that confront administrative supervisors, the nurses who are in charge of the hospital when the Monday through Friday day shift leaders go home. They are the on-site leaders for evenings, nights, weekends, and holidays because unit managers, directors, and administrators are not in the hospital. As such, the administrative supervisor represents what some people call “off-shift” nursing management.
In acute care hospitals, off-shift (or administrative) management consists of management after 5 PM on weekdays, and 24 hours on weekends and holidays, which can be calculated to about 128 hours weekly. Administrative managers are present in hospitals more hours each week than unit-based nurse managers, who tend to work the traditional 40+ hour workweek during the daytime hours, Monday through Friday.
Nurse leaders may believe that they have an understanding of this administrative supervisor role, which can be found in acute care hospitals throughout the United States. However, there are little empirical data on this role. This qualitative study was conducted to gain a better understanding of the managerial practices and role responsibilities of the administrative supervisor.
A review of the literature on administrative nursing leadership confirms the lack of visibility of this role. There has been a paucity of articles published before the recent descriptive publications on this management specialty by the principal investigator (PI) of this study.1,2 Only 3 articles, none of which are data based, were discovered in a recent literature search. These include a chronological account of a night supervisor's weekend, a commentary that nursing supervisors should move past the stereotype of “preretirement incompetents,” and a case study on how 1 supervisor dealt with trying to keep employees awake on the night shift.3–5
In the seminal study of magnet hospitals, staff nurses described the importance of supervisory staff, which includes the administrative supervisor, and indicated that the most useful behaviors of leaders included being accessible, willing to help with care, and complimentary to staff for a job well done.6 Staff nurses also specifically identified the evening and night supervisors as being supportive and helpful.6 Nurse researchers have studied the unit-based nurse manager role and found that nurse manager ability, leadership, and support of nurses are important factors in the success of hospital nurse practice environments and are related to increased nurse satisfaction, job enjoyment, quality of care, and decreased nurse burnout.7–9 However, similar research on the administrative supervisor role is lacking. Without a clear understanding of this role, we cannot evaluate the impact of the administrative supervisor on patients and staff. This study will begin to address the gap in empirical data on off-shift management.
The purpose of this qualitative exploratory study, which was conducted from September 2013 through January 2014, was to identify and describe specific managerial practices and role responsibilities of administrative supervisors in acute care hospitals. Institutional review board approval was obtained from Rutgers, The State University of New Jersey for this qualitative study, and, as required, from participating hospital institutional review boards.
Administrative nursing supervisors in acute care hospitals in the mid-Atlantic region of the United States were identified through nursing colleagues who were asked to forward a recruitment e-mail to current administrative supervisors, inviting them to participate in this research study. From the e-mail responses that were received, purposive sampling was done in which only 1 administrative supervisor participant was selected and interviewed per acute care hospital.10 When participants responded to the e-mail, the PI informed them about the study, verified their interest in participating, and arranged for an in-person interview at a time and location that was convenient for the participant. The PI conducted all interviews, which lasted between 30 and 60 minutes. There was only 1 interview session for each participant. An interview guide (see Table 1), consisting of a series of questions and probes, was used to format the interview. Questions were based upon the American Organization of Nurse Executives' competencies for nurse managers.11 The interviews were digitally recorded, transcribed verbatim, and uploaded into ATLAS.ti, a computer software program for qualitative analysis.
The transcripts and field notes were read, reread, and coded by the PI and the co-PI, beginning with the first interview, and ongoing throughout the study. During the interviews, the PI periodically repeated the supervisors' words to check understanding of statements, and the co-PI reanalyzed some of the transcripts.12 In conducting thematic analysis, the researchers utilized an iterative, constant comparative method to identify codes and themes and held frequent meetings to reach consensus. The job responsibilities that the administrative supervisors described were examined and coded. Responsibilities were then grouped into categories. After the seventh interview, the researchers identified that there was consistency within the data and decided to explore in future interviews whether a difference exists with administrative supervisors at American Nurses Credentialing Center (ANCC) Magnet-designated facilities. The researchers recognized, after the tenth interview, that the data were revealing consistent information for the identified codes and themes about this role, and, therefore, saturation was achieved.
The interviews with the administrative supervisors provided information about the job responsibilities along with basic demographics (see Table 2). All of the interviewed administrative supervisors were female, 3 (30%) supervisors worked the evening shift, 3 to 11:30 PM, and 7 (70%) worked the night shift, 7 to 7:30 AM. Four (40%) of the supervisors reported that they generally had another administrative supervisor working with them to cover all the nursing units. Most supervisors (80%) worked for nonprofit hospitals; 3 supervisors worked at an ANCC Magnet-designated facilities; and 1 supervisor worked at an ANCC Pathways to Excellence–designated facility.
Difference of the off-shift
The overarching theme that became evident in the interview with the administrative supervisors was the perception of how differently the hospital is managed at night and on weekends. Management, workflow and decision making is not done the same way. There are fewer resources, less staff, and more on call personnel on off-shifts. Administrative supervisors explained that the staff and administrative supervisors feel “disconnected” from resources and opportunities available to day shift staff. As 1 interviewee described this: “If you are working the night shift, you feel disconnected because nothing is geared toward you. The in-services are not geared for you” (supervisor E).
There is also a different management structure, with 1 or 2 administrative supervisors per shift as compared with the multiple daytime unit-based nurse managers. The administrative supervisors consistently stated that they oversee and do “everything.” They are the “go to person,” and they keep the hospital running. One stated: “(I) am responsible for all departments in the building at night; everyone's problem is mine at night” (supervisor E). This can result in a more independent, problem-solving approach among staff and supervisors. The reality is summed up by another supervisor statement: “You get used to it after a while. As nurses we make do; we figure something else out” (supervisor A). The administrative supervisors verbalized a sense of autonomy because they take care of issues or problems and rarely call other managers or executives for backup or assistance in problem solving. However, these supervisors did not seem to have roles in the organization's management-level planning. They saw their role to get the staff, patients, and, ultimately, the hospital, safely through each evening or night shift. This sense of difference framed the responsibilities described by administrative supervisors, which fell into 3 categories or subthemes: staffing and patient flow, crisis management, and manager support for the staff (see the Figure).
Staffing and patient flow
Staffing and patient flow were grouped together because these tasks impact each other. Census changes are directly correlated to needs for more or less staff. All interviewed administrative supervisors identified the tasks of staffing as a primary responsibility, although the majority (60%) of the administrative supervisors had support personnel to assist with staffing. Staffing involves ensuring that the appropriate nursing staff matches the hospital patient census and acuity for the present shift as well as the next shift. Three key aspects of staffing were addressed by the administrative supervisors: obtaining staff to replace scheduled team members who are absent (covering “sick calls”), calling in on-call staff, and patient flow/unit assignment (see Table 3 for quotes). The administrative supervisors' explanation about what staffing involves was summed up in these words: “you check on the census, see what type of staffing you need for the next shift. You consider whether you need to cancel anybody” (supervisor B) while “trying to be fiscally responsible and make sure you are staffing to the current census on the unit” (supervisor G). The administrative supervisors stated that staffing is a challenge. However, they like to figure it out, and as one off-shift supervisor summarizes it:
The most challenging thing for me is staffing, only because I like to get it right. I don't like to short anybody. I find I stress more over the staffing. I want to make sure that everybody has what they need. (Supervisor E)
Another key role of the administrative supervisors is crisis management, which includes dealing with unexpected emergencies, responding to all codes, and dealing with patient and physician issues (see Table 3). The administrative supervisors described problem-solving approaches used when dealing with unique situations, such as calling the police for assistance when one supervisor received a phone call from a man threatening a nurse who was on duty, or dealing with building issues such as smoke in the building or power outages.
Manager support for the nursing staff was a category that emerged in the interviews. This encompasses 4 categories: being available, providing resources, serving as a management resource, and demonstrating care for the staff. The theme of manager support is illustrated by the following story that an administrative supervisor provided:
We had a maternity unit where we had a mom who went into cardiac arrest with an amniotic emboli. And of course... [the nurses] on maternity, they're not used to that kind of crisis. So I, of course, responded to their code. Then I called people who could take over. They were above and beyond their capability at that point. The woman did pass away and Dad brought home a very healthy baby. It was very tragic for the nurses. They took it hard. But then it's so good to hear them a week or so after the event thanking you for being there and getting things rolling faster than they would have, if they were on their own. (Supervisor C)
This administrative supervisor was available and present during the code, demonstrating caring for the staff by her recognition that they needed help dealing with this tragic event.
All administrative supervisors discussed the importance of being available or visible to the staff by making rounds, helping with whatever is needed, and assisting with clinical skills and procedures, such as inserting intravenous and urinary catheters. The following administrative supervisors' statements illustrate availability:
My philosophy has been to go to the problem area. Go to the areas and be seen first. Just let them know you are there for them. That's half the challenge to have them see you. (Supervisor G)
There are certain areas in the hospital that are only staffed with two nurses. So I will go up at night ... and relieve them so they get their break. (Supervisor D)
Administrative supervisors enable staff to care for patients by obtaining resources, such as supplies, food, and medication. Delivery of medical supplies was discussed in the interview and summed up like this: “We are responsible for delivering the equipment .... We go down to central to get what's needed and deliver the code cart” (supervisor G). An administrative supervisor explains the importance of this duty:
Medical supplies, some people think, I am a RN, why should I have to do that? But, it's not about that, it's about the patient and it's about helping your staff members get through the night. Because without those supplies they can't do what they need to do, and the patient can't get taken care of. (Supervisor F)
Medications are also obtained by the administrative supervisor when the pharmacy is not staffed: “They call me for the medication if it is not in their PYXIS, so I will go down to the pharmacy and get the medication” (supervisor E).
An additional resource that the administrative supervisors provide is food, such as sandwiches or bottled water for hungry patients, because the dietary department is closed.
Serving as a management resource
The administrative supervisors indicated that they are a resource for the staff through their role of providing policy information and educating the staff on new equipment. Providing staff with policy information is an important aspect of the administrative supervisor role. The administrative supervisors are experienced nurses, and serving as mentors is a natural part of the role. When relating a specific story, a supervisor shared: “I helped guide her as if I were the educator on the night shift, to show her how to manage the drainage of the abdomen” (supervisor F). Another administrative supervisor explains, “I guess I just like to be able to mentor the nurses.... I just like to be able to see new nurses grow. A year after they start, they're doing different things” (supervisor A).
Caring for staff
Just as nurses care about their patients, the administrative supervisors care about their staff. The interview data indicated that administrative supervisors listen to staff, encourage staff, and support staff. An administrative supervisor explained,
They will just say, ‘you know we only have three nurses tonight'. I let them know I am sorry about the situation, and that I am there for them. You just have to try to make people feel good. We're going to get through it ... I buy them bagels and pizza if a particular floor has a hard shift.” (Supervisor D)
Weekends and night shifts that are characterized by certain services not being available and less direct supervision of staff have been confirmed by other researchers.13–16 In one qualitative study exploring the differences between weekend and weekday environments, the surveyed nurses explained their desire to have night/weekend supervisors check in with them to see whether the nurses needed management support.13
All administrative supervisors interviewed in this study explained that they “oversee everything and keep the hospital running,” regardless of whether or not they work at ANCC Magnet-designated facilities. The administrative supervisors consistently reported that their work involved responsibilities for staffing and patient flow, crisis management, and management support for the staff. Manager support, such as providing resources, serving as a management resource, and caring for the nurses, is described in the literature.17–20 In one study, hospital staff nurses were interviewed about the unit-based manager behaviors that influence their job satisfaction. They gave examples of managers providing support to the unit, such as “being on our side,” and “going to bat for the nurses with physicians or abusive visitors.”17 Other researchers have defined manager support as being available and accessible to the nursing staff to provide assistance with job-related problems that links to the findings in this administrative supervisor study.17–20 While the studies refer to unit managers, their findings correlate.
Delineating the administrative supervisor role responsibilities begins to provide a better understanding of management during weekends and night shifts. A recent systematic review of the literature revealed that the hospital environment when the Monday-Friday day shift personnel go home may be associated with poor patient and employee outcomes. There was no mention of administrative management in this review.21 Future research should be conducted to include an examination of the administrative supervisor role responsibilities and their relationship to nurse and patient outcomes. A variety of studies could provide information to inform hospitals of best practices for weekend and night shift management models. In addition, the influence of having an administrative supervisor who is available and supportive on nurse satisfaction and the nurse practice environment needs further investigation. Researchers should explore the engagement of the administrative supervisor with the rest of the nursing management team, with regard to appropriate involvement in planning and implementing the goals and objectives of the nursing department and hospital.
The findings of this limited qualitative study in the mid-Atlantic region of the United States may not reflect the experiences of administrative supervisors in other parts of the country. The researchers obtained a representative sample with administrative supervisors from hospitals with both for-profit and nonprofit ownership and hospitals with and without ANCC Pathways to Excellence designation and ANCC Magnet designations. However, we were unable to recruit male administrative supervisors.
An administrative supervisor with responsibility for ensuring that the hospital continues to function smoothly and efficiently is a current model of weekend and night shift management in many acute care hospitals. This research delineates administrative supervisor managerial practices and role responsibilities for staffing and patient flow, crisis management, and manager support for the staff. It begins to provide a better understanding of 24-hour, 7-day-a-week management.
Independent, autonomous administrative supervisors are the hospital leaders during most hospital hours. They are challenged to “getting staffing right,” perform emergent problem solving, and support a nursing staff with limited additional resources.
Nurse researchers should continue to examine the administrative supervisor role to provide evidence of best practices for effectiveness and efficiency in this role, along with findings on the impact of the position on nurse and patient outcomes. As the administrative supervisor role is further investigated, discussion of the best practice models of management should result, along with a better understanding of the practice environment. It is important that organizations and nursing operations leaders gain a better understanding of how the administrative nurse leader makes a difference in the hospital's quality and financial results. As we move into the next era, we will need more complete information to improve all of our practices. We will be better situated to add value for our patients when we have a more complete picture of the value provided by “off-shift” administrative supervisors.
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