Lesson 8: Nurse Manager’s Roles and Functions in Hiring, Team Building and Staffing Career Development Stages and Personal Career Development

-Thoughtfully record a personal career development plan-

I always thought I had the path my nursing career would take mapped out. Go to school, graduate, pass NCLEX and get my RN, get a job at the hospital (preferably in labor and delivery).  Simple as that. I'd gotten every job I'd ever applied for...until I graduated from nursing school. I had applied to over 80 jobs and had only TWO interviews in the space of a year. I knew the economy for nursing jobs in UT was tough, so I wasn't too discouraged until one of my classmates who had never had a job, EVER, had interview after interview and was hired at UVRMC. Needless to say, the career path I had always imagined did not come to pass...

I recently, like 8 weeks ago, started working as THE nurse at a residential treatment facility for teens. While I love my job, and I truly do, I have struggled with accepting the title of nurse in this role because it is not what I envision a nurse to be. When I pictured myself as a nurse I pictured myself in scrubs, walking the halls of the hospital, providing bedside care, and (ideally) helping to bring new lives into the world. Reconciling my current job with my identity as a nurse has been challenging, and the path I always envisioned and planned on my career following has taken an unexpected turn. So, currently my career path is under construction. I'm grateful to have a job that I love, pays the bills, and is willing to work with my crazy school schedule. The last few years have been so crazy and busy I'm excited to graduate and enjoy traveling down the career path on cruise control for a year or two. Then, I'll pull out the map and re-evaluate where I am and where I want to go.

Goal #3: Learn more about the balance the budget. What's involved? What are the different parts of a budget?

If anything turns me off of ever aspiring to positions of leadership or management, is the four letter word BUDGET. I learned, today, that the budget is something that Dave must think about on a daily basis. Each morning his secretary and right hand, Elaine, bring him a report of the employee hours. It lists how many hours each employee is allotted each pay period, how many they are working that day, and how many hours they are scheduled for the day. The purpose of the report is to help him stay on budget in the area of staff salary.

The topic of staff hours was a hot button issue today. the budget from the previous week showed that UVOC Surgical Center was 5 FTEs over budget. Before we could get anywhere, Dave had to explain to me what an FTE is. One FTE is worth 40 hours, so it is equal to one full time employee's hours. This means that for the week prior, the surgical staff had worked 200 extra hours. Not a good thing. Elaine came in and she, Dave, and I went over the prior weeks schedule to locate where the extra hours were worked, as well as the schedule for the coming month. It was really interesting and educational to see the process in motion. We found that one place a lot of time was being wasted was in the department of the anesthesia techs. On the days that there is a short shift, one tech comes into relieve another one. Time was being lost because the on coming tech was not as fast as they could changing into their green scrubs and getting report as quickly as they could. Then, too much chit-chatting was happening during report. Lastly, the leaving tech was not as quick as they could be in changing back into their street clothes and clocking out. After this was determined, Dave called the anesthesia techs into his office and had a short huddle to explain the situation and ask them all to do better.

So, today I saw just one aspect of the budget and staying within it. I'm sure there will be other opportunities to learn more....lots more.

Clinical: Day Three

Today Dave and I were, finally, able to discuss what I might do for my project and I think we've got it pinpointed! Back in January where there was a situation and a Code Red alarm went off. However, there was no overhead page, so the staff assumed it was a mock code and did not do anything. It wasn't until the fire department showed up that everyone new there was a real situation. Also, the PBX operators, that are in charge of notifying engineering and security, did not let anyone know that an alarm was sounding.
So, for my project, I'm going to rewrite the Code Red protocol for the surgical center. I think this will be a good project for me to work on. I'll need to meet with someone from the engineering department as well as PBX to identify where the communication breakdown are happening, as well as what should be happening during a Code Red situation.

Lesson 7: Managing Healthcare Resources

I struggle with the topic of health care budgets. I became a nurse because I want to help people. I know I've said it before, but the further I get into the bachelors program, the more I find out that nursing has evolved into an entirely new animal, and the less certain I become that I want to be a part of it. Healthcare is a business. I understand that it always has been, but it seems it's becoming more about padding the pockets of business men than serving others. Budgets are an important part of business, even a business that seeks to help others. However, I feel there has got to be a balance.

If I you'll allow me, may I illustrate with a story:

I started working as a CNA when I was 16. I worked at a 30 bed skilled nursing facility that had been owned by the same family for over 30 years. The owner, Maxine, did not actively work at the facility, but she was very involved. She knew all the residents and their families. Her daughters worked as nurses, and recreational therapists, grand kids worked as CNAs and kitchen help, and those of us that which were not family were made to feel like we were. Staff ate what the residents ate. Our pay was competitive. The best briefs on the market were used for the residents. The budget was maintained and the owner still made a good amount of profit and lived a comfortable life. Then, through some rather unfortunate and rather sneaky turn of events, the business was purchased by a couple of men who sought to create a chain of nursing homes. They wanted to make money. The new owners changed to a cheaper brand of brief, and increased cost to residents. The new brief were still considered within the guidelines of quality care, but they sucked! Funny I should remember the briefs the most. Food quality went down and staff no longer was allowed to eat food from the kitchen. To make a long story shorter, patient and staff satisfaction declined greatly and within 5 years the facility closed. I suppose this is what has embittered me to the money making side of health care.

Lesson 6: The Nurse Leader’s Role in Managing Change

As is expected, I am resistant to change. However, everything changes. As the old adage says, the only thing constant is change. It usually seem I've just settled comfortably back into life when the winds of change blow again. Usually, it's not until after the page has been turned that I see the benefits of the change. the funny thing is I spend a lot of time and energy wishing and hoping for change. I seem to live my life waiting for change, for when school is over or when I have a better job, instead of living in the now. So I suppose I see change as a double edged sword. 

I have learned some tactics for embracing change more readily. One of which was even discussed in the book, so I must be on the right track! My preferred tactic for change is planning for change. If I am in control of the change, I always feel better. I can make my list, check it twice, and see the progress of the change. This same process works if I am not the one in charge of what is being changed as well. As the book points out, when I am included in the process I feel that I my opinion is valued and therefore, I am valued as well. It also allows me to plan, making the change to which I am resistant a little bit easier to handle.

Goal #4: Understand the role of the unit in promoting patient satisfaction including the best care

Funny that the clincal goal listed as number 4 is the first one I feel was accomplished. Today Dave showed me how patient satisfation is recorded in HCAHPS scores. These are reports that track the units deficiencies and goals met, and are based of the WOW cards that patients are asked to fill out before being discharged to go home.

After we reviewed the HCAHPS scores from January, Dave explained that there are certain steps he takes to help improve these scores. One way is by patient rounding. The nurse manager is responsible to round on a certain number of patients per week to find out the quality of care the patient has been given as well as offer any care that is needed at that time. During our rounding that day, most of the patient and family were so nice, but I was suprised by the few that had negative things to say about their time at the surgical center. It was then Dave's job to try and smooth things over so the patient would leave happy... and hopefully their stay would reflect positively in the HCAHPS scores.

Another thing that contributes to patient satisfaction are the "Thank you" cards that are sent to each patient. This is delegated out the the nurse responsible for the individual patient. At first I thought it was pretty cheesy to send out a generic card that everyone hurridly signs, but then I saw that the nurses were actually writing things that were applicable to each patient and the interaction they had with them.

The WOW cards are given to Dave daily and he sorts through them and analyzes what factors contributed to the patient be satisfied with their care. Some of them are reallly fun to read. The ones that aren't so WOW (I think they are OOPS cards) are usually for things beyond the control of any staff. For example, a surgery has run long so the next case ends up getting started late. If the OOPS cards are very disconcerning, I've seen Dave make phone calls to the individual families to apologize for their unpleasant experience.

So, overall, the until manager has a large part to play in promoting patient satisfaction.

Clinical: Day Two

Today I had an opportunity to see a bit about the various roles and responsibilities of the nurse manager. all I could think was, "Poor Dave."  It was also an example how one event has a ripple effect on all the areas of the surgical center.

It all started when Dr. A an additional case on his morning case load that the surgical center was not aware of. Apparently, t It wasn't a big surgery and would only take about 45 minutes to complete. So, the OR charge nurse let the SDS charge nurse know to make the pre-op patients aware that things were running a little bit behind. Then, the OR charge nurse called the next surgeon, Dr. B, to let her know that her cases would be starting about 30 minutes late, to which Dr. B replied she was going to cancel all her cases for the day. Turns out, this particular surgeon has done this before, and then called back and states she changed her mind after the patients had already been called and told their surgeries were cancelled. So, Dave gets busy calling Dr. Bigler (the surgical center's medical director) to explain the situation and the staff's concern that once they call and cancel Dr. B's patients for the day, she will again change her mind and they will be in a new mess. Dr. Bigler relay's that he had spoken with Dr. B the previous night and that she was having a difficult time finding a proctor to attend her surgeries and that he was surprised to learn she hadn't called and cancelled her cases the night before. Dave then get's on the phone with Dr. B to confirm that she is not coming in and find, in fact, that it is the lack of a proctor that is the problem and the 30 minute delay was the out she needed to cancel her cases. After speaking with all of the doctors, Dave then gets on the phone personally calling to cancel Dr. B's patients and apologize for the inconvenience.

The situation was so frustrated and could have been prevented several ways. First of all there was a communication breakdown between Dr. A's office and the surgical center. Because UVOC didn't know of the additional case until the patient was checking in, that set things back about 30 minutes. Secondly, if Dr. B had called and cancelled her cases the night before, instead of waiting until 30 minutes before her patients were supposed to arrive at UVOC. I'm sure the patients were frustrated as well, because they had not eaten since midnight and had cleared out the entire day for their surgeries.

I was very impressed with Dave and how well he kept his cool and handled the situation. He communicated with his staff effectively and efficiently and I was also extremely impressed that he took the time to call the patients himself when it would have been easy to delegate, or pass it off, to one of his nurses.

Clinical Goals...

After my first clinical rotation, I feel I've been able to come up with some good goals.

1. Understand the organization of the UVOC health care team(s) and how they work together to meet the needs of the population they serve.
2. Understand the "path" of the patient receiving treatment at UVOC and how the nurse manager influences each step/what the nurse manager is responsible for within each step.
3. Learn more about the balance the budget. What's involved? What are the different parts of a budget?
4. Understand the role of the unit manager in promoting patient satisfaction including the best care.

Lesson 5: Organizational Structure, Power and the Role of the Nurse Leader

The patient care model that is used at the residential treatment program where I work is probably most like that of primary nursing. As the only nursing/medical position on staff, I am responsible for seeing that 100% of patient care is met. My position requires that I develop a relationship with each of the 44 student currently enrolled in our program so that I can get to know their needs specifically and individually and then make a plan to ensure those needs are met. It is my responsibility to communicate with other members of the professional community (including local physicians, dentists, and mental health professionals) and the other members of the treatment to to see that the students medical needs are met. I am also the liaison between the parents and all medical treatment, which also requires that I communicate all medical needs, treatment, and follow-up to the parents of each student.

Power: That which enables one to accomplish goals.
The book describes several different types of power:

• Reward power is gained by grant favors/rewards. 
• Coercive power is punishment power,  which is based on the fear of punishment (transfer, layoff, demotion, or dismissal).
• Legitimate (authority) power is obtained by a title or official position within an organization.
• Expert power is power through knowledge, expertise, or experience.
• Referent power is gained when others identify with that leader or with what that leader symbolizes. 
• Charismatic is personal power. Informational power is gained when people have information that others must have to accomplish their goals.
• Self-power (feminist power) is the power a person gains over his or her own life, which comes from maturity, ego integration, security in relationships, and confidence in one's impulse.

 I feel personal power increases naturally some degree through the process of maturing and growing up. I can help this process and increase my base of personal power as I continue to work to strengthen the personal relationships I currently have, as well as the establishing of new ones. I can further increase my sense of personal power by achieving better balance in my life between work and play. Also, the success seen after the successful accomplishment of newly acquired nursing skills definitely increases the feelings of personal power. I also believe that personal power increases when we aid in empowering another.

I've struggled with people in power in my life because they have often used it in an authoritarian and threatening manner. However, when I started working with mothers over coming substance abuse, a large portion of the psycho education groups were on reclaiming power over your life. I learned so much about myself working there. I think that is why I love the definition of power in the text as that which enables one to accomplish goals. I'm still working on allowing myself to be powerful and to see my goals come to fruition.

Clincal: Day One

I had my first day of clinicals today. I am working at Utah Valley Surgical Center at the Utah Vally Outpatient Center...also know as UVOC...with David Kay. I am grateful to have this opportunity, but at the same time, not nearly as excited as I was during the clinicals for my ADN. I really love hands on patient care and performing the tasks I associate with "being" a nurse. However, I know that I need to be exposed to the other areas and responsibilities of nursing. And, who knows, perhaps it will change the rather poor opinion I have of the business healthcare has become.

One fun thing that happened today: David had a personal appointment to attend to for about an hour this afternoon, so I was able to go into the OR for a rotator cuff  repair. I was standing in the OR trying to stay out of the way as the patient was wheeled in and one of the nurses says, "Somerset! How are you?" I was caught so off guard! First of all, I was completely dressed in...the only part of my body that was visible were my eyes. Secondly, I had no ideas who's eyes were looking back at me. Turned out to be a girl that lived up the street from me until I left on my mission. When I asked how she knew it was me under all that green she said, "I'd know those eyes anywhere."