Nursing in the new millennium: Ten skills every nurse manager will need
Managers must be able to communicate effectively, meet new challenges
Exploding information technology. The ICU without walls. An increasingly frustrated, aging work force. These are just a few of the challenges awaiting nurse managers in the new millennium.
As critical care nursing enters the 21st century, the successful manager will be one with strong people skills and the ability to adapt under rapidly changing circumstances, according to a sampled cross section of critical care leaders.
Nurse managers’ skills will be tested on many fronts, including financial management, adaptability to increasing responsibilities, and the ability to transition from authority figure to collaborator in partnership relationships with others, including physicians.
The good news is that the health care world is shrinking. The ICU is becoming an integrated part of other segments of health care delivery such as acute care and home care. As a result, the ICU manager of the future is likely to function as a member of a network of nursing care professionals in a broad continuum-of-care team environment.
The bad news is that head nurses are likely to inherit a bigger scope of practice and a larger piece of the health care pie to oversee. Furthermore, issues such as the severe nurse shortage, increasing patient census and acuity, and outside pressures to make the ICU a responsive yet cost-efficient engine are not likely to go away. Rather, they’ll demand quicker action and new responses, experts say.
"These are not new skills for managers," says Justine Medina, RN, MS, CCRN, a clinical practice specialist with the American Association of Critical Care Nurses in Aliso Viejo, CA. "Most managers already possess these abilities. But they’re going to have to really hone these skills to meet the changing environment."
People skills will be paramount
Topping the skills list and ultimately affecting all others will be the manager’s ability to work with people — the nursing staff, physicians, administrators, and third-party payers. Indeed, everyone interviewed by Critical Care Management for this report spoke about people skills as an absolute requirement.
"I call these ambassador skills," says Medina. "It’s the ability to communicate effectively, to deal with adversity, to make people feel like they are important and a part of the solution [to problems]."
"The head nurse of the future will have to be a true caretaker of the ICU. Someone who has the keen ability to work with people and their differences," says Debra Byram, RN, MSN, a nurse consultant in acute and critical care with the National Institutes of Health in Bethesda, MD.
Supplementing the menu of new millennium skills, the manager of the future also will have to:
• Understand and work with complex information systems. "The ability to study, analyze, and interpret patient data and work with ease in a technology-oriented environment will be a must for the future nurse manager, according to Tom Rainey, MD, an intensivist and president of CriticalMed, a hospital consulting firm in Bethesda.
"It’s not just the data but the information process itself that will make demands on managers’ attention," Rainey says. Virtually everything known about patients from their acuity level to the cost of their care is translated into digital language and stored in information systems, which in turn make the ICU a small but integral part of a much large complex of a data-dependent health care delivery system.
Furthermore, new information regarding patient classifications, severity of illnesses, and quality-of-care benchmarks are filtering into hospitals daily in digital form. Managers who don’t understand the Web and other technologies will not keep pace, Rainey adds.
• Adapt quickly to an expanding universe. The traditional ICU’s walls are breaking down, and critical care medicine is moving rapidly into new and uncharted territory. Patients are being discharged from the ICU directly into intensive home care programs under supervision of licensed critical care nurses.
The shift to home care is still isolated but already shows signs of becoming a trend in neonatology. Payers and patients’ families have a common interest in getting babies home as quickly as possible where they are likely to do better, says Frances Strodtbeck, RNC, DNS, co-director of the neonatal nurse practitioner program at the University of Cincinnati School of Nursing.
The ICU manager will have to learn the landscape and adapt quickly to its demands, says Strodtbeck, who also serves as president of the 12,000-member National Association of Neonate Nurses in Des Plaines, IL.
• Respond to an aging work force. A critical task for the manager of the future will be the ability to effectively address the severe nurse shortage in critical care, according to some experts. "We have yet to see the full effect of this crisis," Medina says.
Staff development, recruitment, and retention are likely to become the biggest challenges in nursing in the new millennium, says Byram. Mentoring young nurses and cultivating new nursing school talent will become priorities. The present median age of nurses in critical care and certain other specialties is 45. New nurses are reluctant to go into intensive care, and nursing staff turnover at hospitals in large cities and rural areas alike has defied efforts to reverse a growing shortage.
The aging factor will raise concerns about productivity, nurse-patient ratios, declining skill levels, and potential on-the-job injuries. The new nurse manager "will have to pay attention to the ergonomics of the ICU and create a stable, receptive work environment where nurses will feel needed and supported," Byram notes. The nurse of the future will have to manage not only people but their working environment as well.
• Participate in evidence-based research. Encouraging nurses to incorporate evidence-based research into clinical practice is already occurring in some ICUs but will accelerate as clinicians continue to face concerns from payers for better, faster patient outcomes. Advanced practice nurses, nurse educators, and clinical specialists are playing important roles in knowledge transfer, says Byram. Savvy nurse managers can help facilitate those advancements by encouraging best practices and prioritizing new learning among staff.
• Identify and promote similar incentives. The ability to work with colleagues outside the ICU is likely to become more important as step-down and intermediate care units flourish and patient lengths of stay are trimmed, Rainey says. The nursing world is increasingly becoming a place where managers have to negotiate and align their incentives with others to get things done, he adds.
Getting patients admitted or transferred in a timely manner should proceed like clockwork, but doesn’t because of misaligned incentives. Everyone is working with separate agendas, Rainey says. Effective managers must build positive relationships with colleagues. That means working outside of the ICU’s narrow box. "The system is built for smooth patient flow, but there are dozens of times in a day when vested interests create traffic jams. The manager of the future will have to know how to sail these waters," he concludes.
Manage environments, not just people
• Manage shifting environments and growing responsibilities. Downsizing and integration are the two biggest operational challenges that will affect ICU nurses in the next decade. The effective manager will have to be a quick study and learn to adapt to sudden drops in allocated beds and census and sharp increases in job responsibility, says Kathleen Taylor, RN, MSN, CCRN, ICU clinical manager at 200-bed Liberty Hospital near Kansas City, MO.
Nurse managers are already seeing their responsibilities double and triple as medical, surgical, and pediatric acute care departments once considered completely outside the ICU’s purview fall under a single critical care management wing. The cost-saving objectives of the trend coincide with efforts to reduce occupancy and save dollars by shrinking the size of ICUs whenever possible, Taylor says.
• Master financial concerns. A decade or so ago, when Taylor became an ICU manager, financial management wasn’t a head nurse’s job. Today without some financial skills, an ICU nursing director will not last long. The ability to create practical, effective budgets that control costs has become an imperative for nursing management, says Taylor.
Ever since health care took on the qualities of a business, nurses and physicians have been thrown into the dual roles of caregivers and entrepreneurs. But the trend has been positive for nursing, Taylor says. More and more nurses have earned advanced business degrees, which in turn have given nurses greater voice and influence in corporate decision-making, which bodes well for nursing’s future, Taylor says.
• Provide leadership in a growing partnership environment. According to veteran critical care nurse Bonnie Wesorick, RN, MSN, the workplace of the future for nurses will be one in which the team will prevail over the individual. In that setting, nurse managers won’t be authority figures as much as lead partners with other professionals such as therapists and social workers.
And they won’t be subordinates clinically to physicians as much as true colleagues in a collaborative relationship, says Wesorick, president of The CPM Resource Center in Grand Rapids, MI, an organization that advises providers on staff development issues.
The emergence of advanced practice nurses already has revealed a trend in which nurses will be relied on for more than bedside management. Their special skills and opinions will be valued in a multidisciplinary team environment. The nurse manager will be one of several important players, Wesorick says. He or she will have to rethink the traditional manager’s role from authority figure to role model, or a "senior partner" on the clinical team, Wesorick says.
• Create new work cultures for the next generation. Currently an embattled group, nurse managers are exhausted by top-down demands placed on them as individuals. But they will not have to go it alone in the new team matrix, says Wesorick. The team model will give managers an opportunity to create healthy working relationships with peers, as accountability for efficiency and patient care becomes the team’s responsibility not just the manager’s alone.
The ICU itself is fast becoming part of a larger integrated organization of diverse clinical specialties. "The whole mindset of separate hospital departments will be gone," Wesorick says. "Managers won’t be unit-focused anymore, but true systems-thinking people."
As gatekeepers of an integrated ICU model, managers will play an important role in maintaining a culture based on teamwork to attract a supply of new nursing talent from schools and mold the graduates into professional critical care specialists, Wesorick predicts.
"Nurses are going to be leading the next big movement in health care because the patient-care process has always begun with the nurse," Wesorick says.
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