CCU managers face culture shock amid system changes, job redesign
Are traditional managers becoming obsolete?
Is the ICU manager’s role becoming obsolete? There’s growing evidence to suggest that it is, according to nursing experts.
At many hospitals, traditional jobs such as staff scheduling and development and unit budgeting — once the purview of the unit manager — are being delegated to others.
Meanwhile, managers are finding themselves moving farther up the management chain into administrative or higher management positions — and once there colliding with culture shock.
Next to the manager’s title, you can add the terms fiscal officer, policy-maker, administrator, even strategic planner. And "each of the names would fit," says Jessica P. Palmer, RN, MSN, nurse manager of medical, surgical, and critical care services at Duke University Medical Center in Durham, NC.
Drastic role changes hit managers
What used to be a relatively straightforward set of duties for most managers has for many been replaced by broader, more demanding jobs.
Seasoned managers are witnessing an almost complete redesign of their job descriptions, a process that began a few years ago, but is accelerating and affecting nearly every major hospital and nursing department in the country, according to nursing officials.
Managers within critical care, especially, are seeing their world turned almost upside down as hospitals carve out new territories for them and consolidate others in the name of cost savings.
As a consequence, some RNs complain that while their salaries have shot up, they’ve gotten farther away from the day-to-day activity of overseeing nurses and patients. Yet, their days are just as long and in some cases, just as arduous.
"Many of these responsibilities have been taken over by charge nurses and shift supervisors," says Palmer.
Clearly, much more is being expected of managers, says Linda Urden, RN, DNS, associate professor of nursing at Indiana University in Indianapolis. "The manager’s position, as we’ve known it, is becoming obsolete."
Today’s manager has to have a broad knowledge of business and financial skills. Leadership and administrative acumen are also important while an ability to coordinate across wide sections of the acute care continuum is becoming more common, Urden says.
Providers aim to be lean and mean
Why is this happening now? Hospitals are eliminating middle management positions in an effort to run leaner and meaner, according to Urden. The aim to is operate with fewer levels of bureaucracy.
Meanwhile, job redesign is occurring at all levels partly fueled by concepts, such as team nursing, self-scheduling, and employee empowerment, which are becoming workplace realities.
RNs who can’t keep up are likely to be overlooked for advancement, no matter how effective they are as managers, according to Tim Porter-O’Grady, RN, PhD, a health care consultant in Atlanta.
And according to some nursing insiders who preferred not be quoted for this article, many seasoned, talented ICU managers are not keeping up. Yet, the need for strong leadership in critical care has at no time been greater, according to experts.
With all the forces pulling at the ICU, "I can’t imagine any critical care unit running without a manager in a leadership role," says Vickie Sheets, RN, JD, director of policy and credentialing with the National Council of State Boards of Nursing in Chicago.
Part of the problem, according to one recent study, is the uncertainty that surrounds payments for health care. Hospitals, in particular, have been altering their operations in a variety of ways to become more competitive.1
The change allegedly has had a negative effect on nurses and other staff, leading to uncertainty about their roles and environment, according to researchers.
For nursing departments, especially those in critical and acute care, the two highest cost sectors viewed by payers and administrators, the uncertainty springs from several causes, including:
•almost daily patient census fluctuations and complex medical care requirements;
•staff shortages and other personnel limitations;
•lack of control over professional practices;
•interdependency among medical departments;
•external organizational pressures such as managed care.1
Nurses feel frustrated, disconnected
The flux is adversely affecting managers, too, whose roles are undergoing a change as a direct result of those factors, researchers says.
In a recent survey, nine acute care managers were asked about their redesigned leadership roles and the challenges they experienced in implementing innovations (in this case a shift from hospital-focused to patient-focused care).
According to the study, each of the nurses felt frustration, disconnectedness, and inadequacy. They also described difficulty associated with being "the central figure in the eye of the storm."2
According to the same study, which was conducted in at Vanderbilt University School of Nursing in Nashville, TN, mid-level managers struggled to keep up with the demands of change. They also wrestled with their recognition that it was important to stay committed to the "uncertain goals of the institution."
The two studies suggest that nurse managers are apt to respond negatively to drastic changes in their environment.
"Managers today feel overwhelmed," says 20-year ICU veteran Beth Teitelbaum, RN, manager of cardiac nursing at Washoe Medical Center in Reno, NV. "They’re trying to keep all the tops spinning and [are] having trouble staying ahead."
Worse yet, Teitelbaum says managers are being taken farther and farther away from their traditional place in direct patient care.
Ironically, she adds, while they’re being given a larger span of control within the hospital bureaucracy, they’re actually losing most of their control.
Why? The reason goes to the heart of the theory that the closer you are to where decisions are turned into action, the lower will be your costs and level of risk. Your outcomes also will be higher and the more sustainable these factors will be, says Porter-O’Grady.
Removing a seasoned manager from the point of service does the reverse. The farther away you get, the less effective you become in a phenomenon first observed in Japanese industrial engineering, adds Porter-O’Grady. "Ownership is a requirement for sustainability."
However on the positive side, allowing nurses to rise to higher positions as directors and administrators within the hospital bureaucracy while keeping their title as managers can be a positive influence, says Urden. "The plus is that as a director, you finally have a greater scope of power to make things happen."
Previous studies have confirmed the importance by nurses and mid-level managers of good communication, high visibility, and committed support among administrators.3
According to Urden, the growing ranks of nurses in executive positions can only improve conditions for the bedside staff.
Perhaps, according to Teitelbaum, the issue is semantics. Whether managers are actually moving upward to different jobs or evolving into something else isn’t entirely clear. It’s not what you call the individual; it’s what they do that matters most. In that case, charge nurses and shift supervisors are becoming the unit managers of tomorrow.
But managers clearly are evolving, Palmer says. "The traditional manager may be obsolete. But it’s clear that the environment is changing and opening up new opportunities for us, and that’s a good thing."
References
1. Geddes N, Salyer J, Mark BA. Nursing in the nineties. JONA 1999; 29(5):40-47.
2. Ingersoll GL, Cook J, Fogel S, et al. The effect of patient-focused redesign on mid-level nurse managers’ role responsibilities and work environment. JONA 1999; 29(5):21-27.
3. Knox S, Irving JA. Nurse manager perception of healthcare executive behaviors during organizational change. JONA 1997; 27(11):33-39.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content