Critical Care Nurse
Critical Care Nurse
Critical Care Nurse
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Critical Care Nurse. 2004;24: 52-64 Copyright 2004 by the American Association of Critical-Care Nurses.
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Management
Leadership Competencies: Knowledge, Skills, and Aptitudes Nurses Need to Lead Organizations Effectively
Diana S. Contino, RN, MBA, CEN, CCRN
Diana S. Contino is the owner of Emergency Management Systems, Inc, in Laguna Niguel, Calif, and a consultant with MedAmerica. She has more than 16 years of leadership and management experience and provides acute care operational assessments, process redesign, and financial consulting. She is experienced in applying profiling tools, establishing collaborative relationships between nurses and physicians, and eliminating barriers between nurses and financial professionals.
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PubMed The healthcare workplace is comparable to what a person sees when looking through a kaleidoscope: PubMed Citation as the moments pass, an endless variety of patterns emerges. Undesirable patterns that have Articles by Contino, D. S. materialized include the widely publicized shortage of nurses in the workforce and the high rates of turnover among nurses. Healthcare organizations increasingly depend on recruitment and retention of nurse-managers to reverse these trends.
Critical care nurses become leaders through a variety of routes, many of which do not include formal managerial training or education. To produce positive results, critical care leaders need effective strategies to manage departmental operations and inspire staff. One strategy used by chief nursing officers, professional nursing associations, and employers is to design and implement formalized critical care leadership and managerial training programs that are evidence based and results oriented. In "Leadership Research in Business and Health Care," Vance and Larson1 report an underuse of evidence-based research in the development of healthcare leaders. The evidence-based research that is available is largely descriptive and is poorly translated into healthcare. In this article, I provide a compilation of practical managerial skills for critical care nurses in formalized managerial roles, as well as leadership skills that are useful for all nurses. These skills are based on my managerial and leadership experience, the findings of numerous experts, and healthcare and business resources. The highly divergent and dynamic leadership skills described herein mirror the responsibilities of critical care managers. The skills also illustrate the need for open-minded leaders who collaborate with colleagues and peers to prepare for and respond to the multifaceted challenges that arise every day. For purposes of clarity, the leadership skills are grouped into 4 main categories: 1. 2. 3. 4. organizational management communication analysis/strategy, and creation/vision.
Included in each of these categories are key skills and abilities that make leaders effective. Although the categories are an artificial separation of skills that intertwine and overlap, the skills are discussed separately for the purpose of explaining each skill and demonstrating its applicability. Despite the expansive nature of this topic, the examples are brief; the references cited provide additional information and resources. Administrative teams can use these leadership skills as the foundation to create competency-based job descriptions and development programs for nurse-leaders. Table 1 summarizes the skills reviewed in the following paragraphs.
View this table: Table 1 Nurse-leader competencies [in this window] [in a new window]
Managing Time
Effective leaders use successful strategies for time management. Often leaders allow minutes and hours to be wasted on nonessential tasks such as opening mail, filing, and responding to noncritical requests from others. Effective leaders use self-discipline to organize these tasks and assign priority to projects that produce results. By learning from management experts such as Stephen Covey, nurses can perfect their time management skills. In his book, The 7 Habits of Highly Effective People, 6 Covey eloquently describes a time management matrix that provides a guide for understanding the relationship between important, not important, urgent, and nonurgent activities (Table 2 ). This tool encourages leaders to focus most of their time on nonurgent activities (quadrant II).6 For example, a directors budget (quadrant II planning and quadrant I deadline-driven projects) is due in 3 days and a friend calls to get advice on vacation plans. The director correctly responds by asking the person (quadrant III interruptions and quadrant IV some phone calls) to call the director in the evening at home. If a leader participates in activities in the upper right corner of the top part of the table, the results outlined in the upper right corner of the lower part of the table will ensue. Planning will result in vision and perspective; whereas the continual management of crises will result in stress and burnout (Table 2 ). A leader can use this matrix to prioritize tasks and responsibilities, reducing time wasted on nonurgent activities. This example is an easy distinction; however, managers face much more subtle choices, making the disciplined use of the matrix even more important.
View this table: Table 2 Time management matrix [in this window] [in a new window]
A leader can use time efficiently while building staff members self-esteem, as exemplified by the concept of 1-minute praise described in the One Minute Manager.7 Finding creative, quick, and individual ways to thank staff members, colleagues, and customers is an important leadership skill. Effective time managers find easy ways to acknowledge staff, such as keeping thank-you cards tucked in their organizer or putting reminders in their personal digital assistant. While waiting for meetings to start, leaders write thank-you notes to staff members and others who exhibit exceptional behavior and mentoring activities. The personal acknowledgment of staff members builds morale and improves retention.8 Delegation skills are critical to a leaders ability to manage time. Leaders do not have to do everything. Their role is to ensure completion, monitor ongoing progress, and affirm that interventions produce results.9 A leaders effectiveness is maximized by assigning appropriate tasks and projects to staff nurses and other administrative support personnel. Ales10 describes a 4-step process that guides readers through the art and science of delegation: choosing a task that can be delegated, assigning it to the right person, communicating clear instructions, and
soliciting feedback.10
Managing Information
Managing information is critical to a leaders success.9 Without timely statistics and outcomes data, managing in accordance with budget targets and performance measurements is difficult. Effective leaders are able to share statistical and outcomes data with staff members to gain the members participation in meeting budget targets. Additionally, comparing internal (benchmark) data with data from similar organizations is helpful. Resources such as the National Database of Nursing Quality Indicators 11 provide data on a variety of benchmarks such as nursing skill mix, nursing hours per patient day, pressure ulcers, and falls. The Advisory Board12 is another resource that showcases a variety of best practices. Collaborating with colleagues, with peers, and within professional organizations is another way to gather information about trends and successful solutions to operational dilemmas. Critical care nurses manage large amounts of complex data about patients, and nurse-managers are required to do the same with operational data.
Combinations of the different preferences can result in 16 personality types. An understanding of the personality type is crucial to a leaders ability to empathize with another person and what that person may be experiencing. The Keirsey Temperament Sorter 19 is a profiling tool based on the theory that every personality has 2 sides. Temperament is partially inherent at birth, whereas character is a set of learned habits or skills. With this tool, temperaments are sorted into 4 basic categories with multiple combinations. Persons with artisan temperaments are predisposed or born to impulsive action; those with guardian temperaments, to responsible service; those with idealist temperaments, to personal development; and those with rational temperaments, to objective analysis. The survey consists of 70 questions and results in a persons profile of combinations. The temperament analysis is a method for understanding a persons character through the identification of the persons learned habits and skills. A newer profile that is nonjudgmental, accurate, applicable, and easy to understand is Time Typing.20 The titles "Past," "Present," and "Future" are metaphors for physical time and are used to explain that opportunity, knowledge, and control are reference points from which persons interpret situations and make decisions. This model also helps persons understand what motivates them, how they gain self-esteem,
how they communicate, and what types of reward systems they prefer. Persons of the Past type are attuned to information and risk aversion. Past-oriented people are very comfortable with gathering and analyzing data and they seek the "truth." Persons of the Present type are attuned to control. They create organization out of chaos and excel at creating and following a plan. They have patience and strive to create stable harmonious environments, often by maintaining the status quo. Persons of the Future type are attuned to opportunity. They thrive on chaos and change. They dont want to miss an opportunity so they dont turn anything down but will quickly abandon things that wont work. Theorists think that people have some characteristics of all 3 types, but everyone has a primary or dominate perspective or "way of looking at the world." Time Typing does not have complex combinations of "types" that require the learner to focus more on understanding the personality profile than understanding a persons decision-making style. It is an ipsative tool that compares the person to himself or herself. Most of the other profiling tools are normative, ranking the person against others and creating a judgmental environment that contributes to selection bias. Time Typing also includes tools to help evaluate team dynamics and a decision wheel that helps leaders facilitate decision making. Its simplicity makes it a powerful corporate training tool. Table 3 is a comparative representation of the 3 types of tools: Myers Briggs Type Indicator, Keirsey Temperament Sorter, and Time Typing.
View this table: Table 3 Comparative profiling tools [in this window] [in a new window]
Understanding cultural norms and diversity is just as important as understanding individuals. Dreher and Macnaughton 21 contend that cultural competence is really nursing competence. As communities become more diverse, it is important that leaders adopt strategies to teach, provide feedback, and motivate persons from different cultural backgrounds and different skill mixes. For example, asking patients to participate in focus groups and report their feelings and perceptions of their treatment allows managers and staff to see the world from the patients eyes, including the patients cultural views and norms. Leadership mentoring bridges the regulatory and subjective aspects of human resources management through the pairing of experienced leaders with novice leaders. To illustrate a type of mentoring, Montgomery22 presents a descriptive method whereby an experienced professor mentors a doctoral student in the needed leadership and administrative experiences. The mentoring of new critical care managers by the chief nursing officer should occur over time and is enhanced through the resolution of increasingly complex situations.
Managing Change
Critical care leaders must respond to new regulations, changing economic conditions, consolidations, and/or hospital closures. Because of the rapidly changing external environment, it is increasingly important to understand how leaders anticipate and implement change.23 Nurseleaders exert significant influence in the change process.24 Menix25 states that "without appropriate educational preparation nurse managers may not have the competencies to effectively manage accelerated change." The article by Menix is part 1 of a 2-part review of the literature and Delphi validation study on change management. (The Del-phi method is a process in which a questionnaire is distributed to experts who independently complete it; the results are evaluated to determine the likelihood that certain events may occur.) Critical care nurses can use this evidence-based information to educate each other about change. Nagaike26 applies the categories of change, identified by change management expert Anthony Robbins, to healthcare organizations and concludes that "clear communication, accurate data and flexible plans are vital to managing effective change and providing quality care." Implementing and responding to change requires that leaders be able to evaluate the change process. Demings model of change, Plan-DoStudy-Act,27 is prevalent in healthcare organizations: 1. 2. 3. 4. Plan: identify and clearly define the problem. Do: develop and implement a solution. Study: analyze the problem, identify the root cause, map the process and what affects it. Act: evaluate the results and make modifications if necessary.
This concept was first discussed by Skewhart28 in 1939 and then made famous in the 1950s when Deming encouraged the Japanese to adopt it to promote continuous quality improvement.29 Carney30 presents a change management model that enables leaders to evaluate the process. Understanding why nurses resist or accept change enables a leader to communicate why change is necessary and to mentor others through the change process.
International studies indicate a global need for financial education for nurse-leaders.15,31,32 Courtney et al31 cite financial management as 1 of the 3 top areas in which development is most needed. Nurse-managers must have basic knowledge of financial management. Interpreting financial statements, understanding performance ratios, and recognizing the time value of money are essential when financial forecasts and cost implications for business plans are being estimated. Understanding cash flow from when a patient registers to the point of collection of the patients bill facilitates the design of effective processes. Leaders must understand how their organizations formulate budgets and how their chief financial officers prioritize capital equipment purchases and expectations for managing in accordance with a units budget. To compile a capital budget, managers must understand the financial implications of leasing versus purchasing, the expected useful life of equipment, and estimated maintenance costs. Understanding how to calculate a return on investment when proposing new technology, such as computerized documentation systems, enables critical care leaders to conduct cost analysis of different systems and options. The chief financial officer may not take proposals for new technology, additional staffing, and/or equipment seriously unless financial justifications are included. Critical care leaders should collaborate with the finance team to understand projections for activity of the health plan, changes in suppliers prices, and demographic forecasts for the community. This collaboration is crucial to budget planning. 32 Forecasting the number of patients expected, salaries, and supplies can be challenging, especially because the number of patients treated depends on external factors. It is important to know the cost per unit of service so that staff and supplies increase as the number of patients increases. Knowledge of expiring supplier and provider contracts helps leaders anticipate the effects of budgeted rates and numbers of patients. Collaboration of nurse-leaders with financial staff helps improve cash flow and the organizations financial health.
Summary
Each organization has unique operational issues and managerial supports. To successfully overcome the challenges faced by an organization, nurse-managers must work with supervisors to hone the necessary leadership skills.
Communication Skills
Communication occurs through speech, nonverbal signals, and written documentation. It is essential that leaders disseminate and interpret information quickly and accurately. A 2-year study33 of Chilean nurse-leaders suggested that leadership is characterized by exerting a positive influence on others through good communication. At the root of effective communication is delivering the message in such a way that the listener will hear it. The concept of "seek first to understand, then to be understood" is one of The 7 Habits of Highly Effective People.6 It is very important for a leader to understand what employees need and want, as well as what motivates them. Simulation and roleplaying are effective methods for improving communication skills.34
Communicating Vision
Leaders should be able to inspire passion for and commitment to an organizations mission by communicating a vision. The mission is what the organization strives to accomplish; in other words, the reason the organization exists. The vision is the creation of a "picture" of how the mission is going to be accomplished. Vision is also about understanding how to rally people around an idea. All operations, education, goals, and strategies should be linked to the vision and should fit in with the overall mission. For example, a hospitals mission could be "to provide access to optimal healthcare in our community." The vision is that the health system "be central in the communitys efforts to be healthy, by creating caring environments for patients and clinicians by using technology and efficient operations." An example of a critical care
divisions vision is "interdisciplinary collaboration to promote a caring and error-free critical care environment and delivery system."
Communicating Change
The healthcare industry is funded in part with government monies; therefore, organizations are subject to considerable regulatory oversight. Regulations, laws, strategies, and technologies change frequently, and great organizations use the knowledge of change management to implement change successfully. The article by Weber and Joshi39 that summarizes the information in current business and healthcare publications about how change occurs at the individual and organizational level is an excellent resource for nurses. Critical care managers need to communicate frequently with staff to reduce the stress of a transforming environment. Timing is everything. Teaching leaders to recognize when employees are overwhelmed and how to intervene to improve the situation is essential.40 Communication is a critical managerial skill, and when effectively used during the change process, it is exceptionally valuable. A key leadership responsibility is communicating effectively with others. Inspiring and leading critical care nurses can be a powerful result of cogent communication. Therefore, nurse-leaders must continually enhance and improve their understanding of efficacious communication mechanisms.
the literature and network with colleagues to determine the best practices. The team leader guides the team by ensuring that the members are meeting or exceeding expectations and operational goals in regards to the admission and discharge of patients.
Business history: The history of the unit, division, or organization should be included if the readers need to know the historical perspective in order to support or approve the business plan. Product or service: The product or service section encompasses an overview of the service or product offered. For example, the burn intensive care unit provides expert physician and nursing care in a clean and comfortable environment that promotes physical and emotional healing as well as education for patients and patients families. Competition: The competition section summarizes the strengths, weaknesses, opportunities, and threats of the organization or unit. Examples of strengths are a new unit with Internet access in each private room or an operating room with robotics. A weakness may be that the physical plant is 10 years old with semiprivate rooms, whereas competitors have private rooms. The profile of opportunities includes discussion about changing demographics. For example, a biotechnology company with 5000 employees is opening a new office next to the hospital, a situation that presents the opportunity to expand workers compensation services to the new companys employees. The description of threats outlines new programs or services offered by competitors, regulatory changes, and new providers offering less expensive services (eg, urgent care centers or outpatient surgery departments). Marketing: The marketing section discusses the marketing strategy. For example, one hospitals marketing strategy may be to profile its profitable service areas, such as cardiovascular surgery, whereas anothers strategy may be to profile its superior customer service. Operations and management: The section on operations and management should highlight the unique operational and management aspects of the critical care unit. For example, how and where the staff delivers services and if the unit or organization is superior in its performance benchmarks when compared with other units or organizations. For example, a transplantation intensive care unit can
promote its large number of kidney transplant recipients, the optimal outcomes for the units patients, and the units excellent customer satisfaction scores. Goals and objectives: The section on goals and objectives includes the goals of the unit or division and the mechanisms used to measure whether the goals are reached. For example, a goal is to improve customer service as measured by customer satisfaction scores. The unit will meet the goals by participating in multiple local and national educational programs to increase staff awareness about customer service initiatives. On the basis of the results, a customer service process improvement team is chartered to assess and redesign processes to enhance services. Financial projections: Financial projections include the financial outcomes of the business-planning efforts. For example, the business plan includes the purchase of a new computerized documentation and order entry system. This new system reduces errors that stemmed from illegible writing and missed orders. Because of the expanded remote access, it also enhances communication with physicians and patients. The financial projection includes the cost of the new system, potential cost avoidance through the reduction of liability, and personnel reductions due to elimination of paper records.
Writing a business plan is similar to the nursing process: assessment, objective and subjective data collection, evaluation, and planning. "How to Write a Great Business Plan"44 in the Harvard Business Review is an excellent reference and outlines the important points of formulating a business plan in greater detail.
Creation Skills
Nurse-leaders create opportunity, value, relationships, and quality for their employees, customers, and organization. For example, implementing a formalized mentor-training program to increase the retention of new graduates is a creative approach to retention. If a manager does not have a "creative" solution to a particular situation, the manager should be able to identify these qualities in others so that ideas for improvement are still brought forth for evaluation and implementation. Emotional intelligence is the ability to manage ones emotions while having awareness of the emotions of others. For example when a nursemanager jumps to conclusions or lets emotions control a situation, credibility as a leader is lost. Responding to staff in a punitive or irrational way is equally devastating to a managers relationship with staff members. Freshman and Rubino45 highlight the importance of emotional intelligence as an essential skill for healthcare managers. A leader with emotional intelligence is socially aware and has the interpersonal skills to listen to and respond appropriately to an employee. For example, while investigating a patients complaint, a leader ascertains that the offending employee was previously subjected to verbal abuse. This knowledge allows the leader to help the employee understand his or her response to the demanding patient and subsequently make changes in behavior to respond appropriately to situations that elicit strong feelings of past negative experiences. Emotional intelligence skills enhance leaders ability to create opportunity for their peers, employees, and customers through self-awareness and self-regulation.
Critical care managers can involve staff in many of these initiatives to improve service delivery. Many organizations are using Six Sigma, a data-driven method of identifying and reducing defects or errors. This system uses define, measure, analyze, improve, and control as the steps to improve operations that fall below standards.
Conclusion
Hospitals today are struggling operationally and financially. The reasons are complex and multifaceted. The widely publicized Institute of Medicine report To Err Is Human49 outlines the prevalence of errors in our systems. External organizations such as the Leapfrog Group exist because employers and consumers want to spend money on quality healthcare services and are defining what quality means to them. Training critical care leaders is an effective way to proactively address operational inefficiencies and ineffective practices in human resources. In this article, I cite numerous management experts, theories, and beliefs about leadership. Leaders should be encouraged to identify their own weaknesses and use these skills and tools to develop and promote competency. In order to foster organizational cultures that strengthen nurse-leaders, job descriptions for critical care nurses and managers should include- leadership skills and expectations. Leadership education and training should be one of many initiatives related to process improvement that incorporate research, best practices, and methods that inspire our current and future leaders.
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