- Email: [email protected]
One Emergency Department's Management Experiment: Leadership by Team
CLINICAL
ONE EMERGENCY DEPARTMENT ’S MANAGEMENT EXPERIMENT: LEADERSHIP BY TEAM Authors: Sharon Braun, MN, RN, CEN, Rebekah Howerton Child, PhD(c), RN, CEN, and Sandra Saborio, BSN, RN, CEN, CPEN, Los Angeles, CA Introduction
After 11 years with the same nurse manager, our emergency department faced a significant challenge when our manager unexpectedly resigned in January 2009. Our emergency department is a trauma center with more than 40 beds that cares for over 80,000 patients per year. Given the complexity of any department that is our size and has our volume, we recognized that it could take months or longer to fill the nurse manager’s position, and we weighed our options for covering the daily operations. With no single internal candidates to act as temporary manager, our departmental director proposed an entirely different model of covering the manager position for our institution: management by team. Leadership Styles
Being forced to define a new leadership style for our department was born out of necessity. Blending individual styles to produce one united management front became one of our challenges over the next 11 months. Although the hierarchical interpersonal dynamics changed dramatically within our department with the departure of our manager, the fundamental needs of our patients and staff, along with the hospital’s goals of patient safety, satisfaction, and outcomes, did not. This added to the importance of our team management working, as well as working effectively.
Sharon Braun is Clinical Nurse IV, Cedars-Sinai Medical Center, Los Angeles, CA. Rebekah Howerton Child is Clinical Educator, Cedars-Sinai Medical Center, Los Angeles, CA. Sandra Saborio is Clinical Nurse IV, Cedars-Sinai Medical Center, Los Angeles, CA. For correspondence, write: Rebekah Howerton Child, RN, PhD(c), CEN, Cedars-Sinai Medical Center, Emergency Department, 8700 Beverly Blvd, Los Angeles, CA 90048; E-mail: [email protected]. J Emerg Nurs 2014;40:56-9. Available online 23 October 2012. 0099-1767/$36.00 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.07.021
56
JOURNAL OF EMERGENCY NURSING
Leadership styles have been linked to high levels of quality patient care and staff satisfaction, and nurse recruitment and retention.1–3 During fundamental shifts in organizations, leadership becomes paramount in the efficacious functioning of a nursing unit. Nursing leadership and nursing managers not only influence their staff but also directly influence patient care. The literature supports that nurse managers significantly influence patient satisfaction, staff absenteeism, patient complaints, medication errors, and staff turnover.2 Managing any hospital nursing department effectively is a difficult task on its own, and this fact is compounded by the current state of health care in the United States. This challenge is made even more cumbersome for emergency departments that are viewed by some persons as a safety net for the uninsured and areas where aging baby boomers are using emergency departments more frequently for chronic health care issues.4,5 Emergency nurse managers of today must be able to adeptly deal with increasing patient volume and other patient care–related issues within the emergency department while collaborating with other departments to expedite the administration of safe and effective patient care. Simultaneously, the emergency nurse manager has to deal with all of these challenges but also concurrently manage staffing issues and patient safety and acuity and balance organizational and regulatory agency requirements. All of the aforementioned issues must be accomplished while attempting to exhibit fiscal responsibility. Patients using the emergency department as their primary care center because of chronic medical conditions or an uninsured status contribute to the obstacles present for financial prudence.5 Emergency departments are required to do increasingly more with less resources, including less reimbursement from the private and public health insurance sectors.5 The reduction of budgets with the cost of care remaining the same or increasing has also contributed to the need to be aware of financial issues.6 Knowing how to use each revenue source to its maximum potential and minimize or reduce waste is essential to the emergency nurse manager’s role. The hospital for which we work is a magnet hospital whose leadership mission is to lead employees with a transformational leadership style. Burns7 first described transfor-
VOLUME 40 • ISSUE 1
January 2014
Braun et al/CLINICAL
mational leadership in 1978. Transformational leadership, in brief summation, is the ability to influence staff toward achieving outstanding goals by changing a follower’s beliefs and needs and by involving employees into the task, team cooperation, and encouraging leadership skills in others.8 A transformational leader is defined as one who “creates and implements a vision of what can be accomplished at work and empowers the staff with that vision, while keeping abreast of health care changes and interacting with others inside and outside of the organization.”1 Transformational leadership is linked to higher levels of employee effectiveness and patient satisfaction in comparison to other styles of leadership.3 We attempted to emulate this as a group as we worked by “team management” and tried to lead in accordance with the organization’s mission and goals, balancing the needs of our patients with the needs of our staff. While attempting this balancing act, we also had to embark on a crash course in emergency nursing management. In contrast to the transformational leadership style, there is transactional leadership, which concentrates on structure, role expectations, and rewards. A key tenet is that every effort must be rewarded or no employee will take any action above and beyond the call of duty, and this approach does not necessarily attempt to foster innate leadership skills in all employees. This type of leadership can be seen as more elementary but, with group management, was at times necessary to get the job done because of time constraints and regulatory requirements.3 A variety of leadership theories and publications exist in the current literature. There are various types of leadership traits, including directive, visionary, affiliative, participative, pace setting, and coaching.2 All of these styles may be used at different times and in different scenarios. A directive leadership style demands immediate compliance and is useful in crisis-type situations or with problem employees. Visionary leaders are those who can give their staff a long-term vision and goal and are instrumental in times of great change. Affiliative leaders are those who have the ability to create a harmonious environment and are able to bring people together in teams and motivate team members toward a common goal. A participative leader helps to develop staff and helps to involve employees so that they feel valuable. Pace-setting leadership is useful when quick results are needed and teams are composed of highly motivated and competent teams. A coaching leadership style appraises the long-term professional development of staff and is implemented when employees need to be motivated to improve. Cook 9 identified 5 different types of effective leaders: shaper, modifier, discoverer, valuer, and enabler. There are also what are considered to be “classic” leadership styles, which include production-
January 2014
VOLUME 40 • ISSUE 1
or task-oriented leadership and employee- or relationoriented leadership. Transformational leadership can be described as a combination of employee-/relation-oriented and change-oriented leadership styles. No effective nurse leader ascribes to only 1 of these types of leadership style; rather, an effective nurse leader implements each style as needed for each situation. We all tried to be aware of the type of leadership trait needed for each situation and implement the appropriate measures needed. In January of 2009, our emergency department had 6 clinical assistant nursing positions, which we refer to as CNIVs (our clinical ladder is from Clinical Nurse I to Clinical Nurse IV): 2 CNIVs on day shift, 2 CNIVs on evening shift, and 2 CNIVs on night shift. To further complicate issues, a day-shift CNIV had recently resigned, leaving us with only 5 remaining members. Each of the remaining members had at least 10 years of nursing experience and at least 4 years of experience as an assistant nurse manager. During the 11 years of working with our prior manager, our responsibilities had grown to include scheduling, staffing, taking charge nurse responsibilities, performing employee evaluations, coaching and counseling employees, and attending meetings of various committees. Taking on the responsibilities of truly managing the department seemed daunting, even to our relatively seasoned group; however, our director assured us that she would assist in those areas in which we believed our knowledge was insufficient. Regarding ourselves as a cohesive group and reaffirming our commitment to our department, we accepted the challenge to manage our department by team during the search for a replacement manager. Because there were 5 charge CNIVs, we each selected 1 consistent weekday that we covered to perform administrative duties with the 2 clinical educators as backup. Meetings were divided up largely according to schedule; that is, a CNIV would attend those meetings that were held on that CNIV’s assigned weekday. One could, however, attend any other meetings that particularly interested the CNIV or in which the CNIV felt deeply invested. When we came to work on our management day, we would report to our director to receive our task list for the day. These assignments included working on particular projects, developing policies, following up on patient complaints, working on the department’s budget, staffing, assisting with regulatory agency visits, and more. Often, an assignment that started as part of the task list grew into a long-term project that the CNIV spearheaded. Routine duties that were automatically included on our administrative days included checking voicemail, reviewing incident reports, and completing patient flow reports. We were also available to cover any sudden problems or issues that arose
WWW.JENONLINE.ORG
57
CLINICAL/Braun et al
on the unit, and staff could drop by to voice concerns just as they had with our previous manager. The physician group and staff from other departments experienced some confusion as to whom to approach as the “buck stops here” person because there were 5 of us, rather than just 1 manager. Generally, many issues were channeled through our director, who then assigned them to whichever CNIV was working that day. Our group met regularly to discuss common concerns and to share in decision making. Because days regularly passed between some of us seeing one another, many discussions were held via E-mail, and for small-scale decisions, this proved satisfactory. Along with the emergency department, our director oversaw 3 other units, 1 of which, like the emergency department, had recently lost its manager. To assist with running these 2 departments during the search for permanent replacements, our director brought in a traveling manager. This traveling manager initially split her time between both units, but after a few weeks, she concentrated her attention mainly on the other department. She was able to do this because our management team was able to successfully cover the majority of the manager’s daily duties; the traveling manager was not needed as much in our department. Opportunities for Improvement and Successes
There were certainly things that could have gone more smoothly. For example, because there was a different CNIV for each day of the week, items fell through the cracks and did not receive the prompt follow-up required. In addition, at times, there was duplicative work when one CNIV performed the same task another CNIV had performed without knowing the task had already been completed. As the weeks and months passed, we became more adept with our group communication, and these omissions and duplications notably lessened. To minimize this problem, we used the tactics of E-mailing daily (sometimes hourly) updates to the CNIV group and of communicating our day’s progress to the director at the end of our shift. The staff noted the decreased presence of the CNIVs in the clinical area as well. This was also a negative result of the team management. Each CNIV was spending 1 less day per week as charge nurse, and many staff members expressed that they missed our day-to-day leadership “on the floor.” This also increased the burden on the relief charge nurses, because they were called to fill in more frequently. Possibly, this could have been ameliorated by selecting a smaller pool of relief charge nurses to cover charge on our management shifts.
58
JOURNAL OF EMERGENCY NURSING
For a management-by-team system to work, a strong commitment is required not only from the CNIV group but also from the director. Many concerns and decisions that the MD group and upper management would ordinarily have channeled through a manager were brought instead to our director, placing an even heavier workload on her. The staff members were already accustomed to approaching the CNIVs for most of their day-to-day concerns, and the departmental director became the next person “up the chain” for any problems that the CNIV could not resolve. There were also many positive aspects to management by team that worked well for the staff and department. Although this style initially was a significant adjustment for our unit, the daily operations of the department continued quite smoothly, and we gradually settled into a new equilibrium. Staff seemed to appreciate the cohesiveness of the group and our commitment to maintaining the standards and expectations of the department while we were in flux. We were very touched when they had a CNIV group appreciation day. Our director showed great confidence in our group and encouraged group autonomy; many decisions regarding promotions, tests of change, and staff issues were made with the understanding that at least 3 CNIVs had to agree. Our previous manager would note that 3 CNIVs outranked the manager, and although not a truism, the concept allowed for rapid and cohesive decision making. This experience was tremendously valuable for our professional growth, exposing us to new experiences that we would not otherwise have had the opportunity to try. As a group, we proved quite efficient at shouldering the workload. Rather than passing undesirable tasks off onto the next day’s CNIV, we took pride in looking for opportunities in each day to lighten our coworkers’ loads, pulling an already cohesive group even tighter. We also became better at communicating, running thoughts and ideas past the group, and gaining insight from others. Sharing the workload spared any one person from carrying the burden alone and decreased the risk of burnout. This management experience also gave us a unique opportunity for frequent face-to-face interaction with our director, a circumstance that is typically rare for CNIVs in our unit. The time we spent working closely with our director has allowed us to come to know her well and has rooted in us a deep loyalty and respect. This experience has also increased our confidence, both as individuals and as a group. During this time, we also had an increase in patient satisfaction scores, which we would like to attribute to our management by team and working closely with the
VOLUME 40 • ISSUE 1
January 2014
Braun et al/CLINICAL
ED staff. Comparing July, August, and September 2009 with the same months in 2011, we found an increase in patient’s “would recommend” scores for the emergency department, “courtesy of ED nurses” scores, and “courtesy of ED staff” scores. Although these were not large changes, we were still pleased with this upward trend in scores.
tion skills, abundant leadership experience, and strong selfmotivation. Over the years, our former manager said to us many times, “I’ll know I’ve done my job when you can step in and take over for me.” It was thanks to her years of mentoring and investment in our professional growth that we were ultimately able to fulfill her leadership mission.
Conclusion
REFERENCES
Our new manager has recently started after more than 1 year of team management. We are happy to have her and happily pass back many of the responsibilities we have covered over the last year, allowing us to spend more time with our clinical duties. Our experience has shown us that should we ever face this problem again, we are capable of doing so. At the same time, our experience has given us greater insight into (and respect for) the management of a department of our size and complexity. This has enhanced our ability to do our job and assist our new manager. It has also given us a greater respect and global picture of the department, as well as the workings of the medical center. Although management by team is not a perfect system, it worked well for our department. This is a model that would only work for a group of nurses who, before the management team by trial, already had strong communica-
1. Casida JJ, Pinto-Zipp G. Leadership-organizational culture relationship in nursing units of acute care hospitals. Nurs Econ. 2008;26(1):7-16.
January 2014
VOLUME 40 • ISSUE 1
2. Kenmore P. Exploring leadership styles. Nurs Manag (Harrow). 2008;15 (1):24-6. 3. Raup GH. The impact of ED nurse management leadership style on staff nurse turnover and patient satisfaction in academic health center hospitals. J Emerg Nurs. 2008;34(5):403-9. 4. Barrett L, Ford S, Word-Smith P. A bed management strategy for overcrowding in the emergency department. Nurs Econ. 2012;30 (2):82–85, 116. 5. Institute of Medicine. Hospital Based Emergency Care: At the Breaking Point. Washington DC: National Academics Press; 2006. 6. LaSalle G. Leadership and the emergency department. Emerg Med Clin North Am. 2004;22(1):1-18. 7. Burns JM. Leadership. New York: Harper & Row; 1978. 8. Duygulu S, Kublay G. Transformational leadership training programme for charge nurses. J Adv Nurs. 2010;67(3):633-42. 9. Cook MJ. The renaissance of clinical leadership. Int Nurs Rev. 2001;48 (1):38-46.
WWW.JENONLINE.ORG
59
ONE EMERGENCY DEPARTMENT ’S MANAGEMENT EXPERIMENT: LEADERSHIP BY TEAM Authors: Sharon Braun, MN, RN, CEN, Rebekah Howerton Child, PhD(c), RN, CEN, and Sandra Saborio, BSN, RN, CEN, CPEN, Los Angeles, CA Introduction
After 11 years with the same nurse manager, our emergency department faced a significant challenge when our manager unexpectedly resigned in January 2009. Our emergency department is a trauma center with more than 40 beds that cares for over 80,000 patients per year. Given the complexity of any department that is our size and has our volume, we recognized that it could take months or longer to fill the nurse manager’s position, and we weighed our options for covering the daily operations. With no single internal candidates to act as temporary manager, our departmental director proposed an entirely different model of covering the manager position for our institution: management by team. Leadership Styles
Being forced to define a new leadership style for our department was born out of necessity. Blending individual styles to produce one united management front became one of our challenges over the next 11 months. Although the hierarchical interpersonal dynamics changed dramatically within our department with the departure of our manager, the fundamental needs of our patients and staff, along with the hospital’s goals of patient safety, satisfaction, and outcomes, did not. This added to the importance of our team management working, as well as working effectively.
Sharon Braun is Clinical Nurse IV, Cedars-Sinai Medical Center, Los Angeles, CA. Rebekah Howerton Child is Clinical Educator, Cedars-Sinai Medical Center, Los Angeles, CA. Sandra Saborio is Clinical Nurse IV, Cedars-Sinai Medical Center, Los Angeles, CA. For correspondence, write: Rebekah Howerton Child, RN, PhD(c), CEN, Cedars-Sinai Medical Center, Emergency Department, 8700 Beverly Blvd, Los Angeles, CA 90048; E-mail: [email protected]. J Emerg Nurs 2014;40:56-9. Available online 23 October 2012. 0099-1767/$36.00 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.07.021
56
JOURNAL OF EMERGENCY NURSING
Leadership styles have been linked to high levels of quality patient care and staff satisfaction, and nurse recruitment and retention.1–3 During fundamental shifts in organizations, leadership becomes paramount in the efficacious functioning of a nursing unit. Nursing leadership and nursing managers not only influence their staff but also directly influence patient care. The literature supports that nurse managers significantly influence patient satisfaction, staff absenteeism, patient complaints, medication errors, and staff turnover.2 Managing any hospital nursing department effectively is a difficult task on its own, and this fact is compounded by the current state of health care in the United States. This challenge is made even more cumbersome for emergency departments that are viewed by some persons as a safety net for the uninsured and areas where aging baby boomers are using emergency departments more frequently for chronic health care issues.4,5 Emergency nurse managers of today must be able to adeptly deal with increasing patient volume and other patient care–related issues within the emergency department while collaborating with other departments to expedite the administration of safe and effective patient care. Simultaneously, the emergency nurse manager has to deal with all of these challenges but also concurrently manage staffing issues and patient safety and acuity and balance organizational and regulatory agency requirements. All of the aforementioned issues must be accomplished while attempting to exhibit fiscal responsibility. Patients using the emergency department as their primary care center because of chronic medical conditions or an uninsured status contribute to the obstacles present for financial prudence.5 Emergency departments are required to do increasingly more with less resources, including less reimbursement from the private and public health insurance sectors.5 The reduction of budgets with the cost of care remaining the same or increasing has also contributed to the need to be aware of financial issues.6 Knowing how to use each revenue source to its maximum potential and minimize or reduce waste is essential to the emergency nurse manager’s role. The hospital for which we work is a magnet hospital whose leadership mission is to lead employees with a transformational leadership style. Burns7 first described transfor-
VOLUME 40 • ISSUE 1
January 2014
Braun et al/CLINICAL
mational leadership in 1978. Transformational leadership, in brief summation, is the ability to influence staff toward achieving outstanding goals by changing a follower’s beliefs and needs and by involving employees into the task, team cooperation, and encouraging leadership skills in others.8 A transformational leader is defined as one who “creates and implements a vision of what can be accomplished at work and empowers the staff with that vision, while keeping abreast of health care changes and interacting with others inside and outside of the organization.”1 Transformational leadership is linked to higher levels of employee effectiveness and patient satisfaction in comparison to other styles of leadership.3 We attempted to emulate this as a group as we worked by “team management” and tried to lead in accordance with the organization’s mission and goals, balancing the needs of our patients with the needs of our staff. While attempting this balancing act, we also had to embark on a crash course in emergency nursing management. In contrast to the transformational leadership style, there is transactional leadership, which concentrates on structure, role expectations, and rewards. A key tenet is that every effort must be rewarded or no employee will take any action above and beyond the call of duty, and this approach does not necessarily attempt to foster innate leadership skills in all employees. This type of leadership can be seen as more elementary but, with group management, was at times necessary to get the job done because of time constraints and regulatory requirements.3 A variety of leadership theories and publications exist in the current literature. There are various types of leadership traits, including directive, visionary, affiliative, participative, pace setting, and coaching.2 All of these styles may be used at different times and in different scenarios. A directive leadership style demands immediate compliance and is useful in crisis-type situations or with problem employees. Visionary leaders are those who can give their staff a long-term vision and goal and are instrumental in times of great change. Affiliative leaders are those who have the ability to create a harmonious environment and are able to bring people together in teams and motivate team members toward a common goal. A participative leader helps to develop staff and helps to involve employees so that they feel valuable. Pace-setting leadership is useful when quick results are needed and teams are composed of highly motivated and competent teams. A coaching leadership style appraises the long-term professional development of staff and is implemented when employees need to be motivated to improve. Cook 9 identified 5 different types of effective leaders: shaper, modifier, discoverer, valuer, and enabler. There are also what are considered to be “classic” leadership styles, which include production-
January 2014
VOLUME 40 • ISSUE 1
or task-oriented leadership and employee- or relationoriented leadership. Transformational leadership can be described as a combination of employee-/relation-oriented and change-oriented leadership styles. No effective nurse leader ascribes to only 1 of these types of leadership style; rather, an effective nurse leader implements each style as needed for each situation. We all tried to be aware of the type of leadership trait needed for each situation and implement the appropriate measures needed. In January of 2009, our emergency department had 6 clinical assistant nursing positions, which we refer to as CNIVs (our clinical ladder is from Clinical Nurse I to Clinical Nurse IV): 2 CNIVs on day shift, 2 CNIVs on evening shift, and 2 CNIVs on night shift. To further complicate issues, a day-shift CNIV had recently resigned, leaving us with only 5 remaining members. Each of the remaining members had at least 10 years of nursing experience and at least 4 years of experience as an assistant nurse manager. During the 11 years of working with our prior manager, our responsibilities had grown to include scheduling, staffing, taking charge nurse responsibilities, performing employee evaluations, coaching and counseling employees, and attending meetings of various committees. Taking on the responsibilities of truly managing the department seemed daunting, even to our relatively seasoned group; however, our director assured us that she would assist in those areas in which we believed our knowledge was insufficient. Regarding ourselves as a cohesive group and reaffirming our commitment to our department, we accepted the challenge to manage our department by team during the search for a replacement manager. Because there were 5 charge CNIVs, we each selected 1 consistent weekday that we covered to perform administrative duties with the 2 clinical educators as backup. Meetings were divided up largely according to schedule; that is, a CNIV would attend those meetings that were held on that CNIV’s assigned weekday. One could, however, attend any other meetings that particularly interested the CNIV or in which the CNIV felt deeply invested. When we came to work on our management day, we would report to our director to receive our task list for the day. These assignments included working on particular projects, developing policies, following up on patient complaints, working on the department’s budget, staffing, assisting with regulatory agency visits, and more. Often, an assignment that started as part of the task list grew into a long-term project that the CNIV spearheaded. Routine duties that were automatically included on our administrative days included checking voicemail, reviewing incident reports, and completing patient flow reports. We were also available to cover any sudden problems or issues that arose
WWW.JENONLINE.ORG
57
CLINICAL/Braun et al
on the unit, and staff could drop by to voice concerns just as they had with our previous manager. The physician group and staff from other departments experienced some confusion as to whom to approach as the “buck stops here” person because there were 5 of us, rather than just 1 manager. Generally, many issues were channeled through our director, who then assigned them to whichever CNIV was working that day. Our group met regularly to discuss common concerns and to share in decision making. Because days regularly passed between some of us seeing one another, many discussions were held via E-mail, and for small-scale decisions, this proved satisfactory. Along with the emergency department, our director oversaw 3 other units, 1 of which, like the emergency department, had recently lost its manager. To assist with running these 2 departments during the search for permanent replacements, our director brought in a traveling manager. This traveling manager initially split her time between both units, but after a few weeks, she concentrated her attention mainly on the other department. She was able to do this because our management team was able to successfully cover the majority of the manager’s daily duties; the traveling manager was not needed as much in our department. Opportunities for Improvement and Successes
There were certainly things that could have gone more smoothly. For example, because there was a different CNIV for each day of the week, items fell through the cracks and did not receive the prompt follow-up required. In addition, at times, there was duplicative work when one CNIV performed the same task another CNIV had performed without knowing the task had already been completed. As the weeks and months passed, we became more adept with our group communication, and these omissions and duplications notably lessened. To minimize this problem, we used the tactics of E-mailing daily (sometimes hourly) updates to the CNIV group and of communicating our day’s progress to the director at the end of our shift. The staff noted the decreased presence of the CNIVs in the clinical area as well. This was also a negative result of the team management. Each CNIV was spending 1 less day per week as charge nurse, and many staff members expressed that they missed our day-to-day leadership “on the floor.” This also increased the burden on the relief charge nurses, because they were called to fill in more frequently. Possibly, this could have been ameliorated by selecting a smaller pool of relief charge nurses to cover charge on our management shifts.
58
JOURNAL OF EMERGENCY NURSING
For a management-by-team system to work, a strong commitment is required not only from the CNIV group but also from the director. Many concerns and decisions that the MD group and upper management would ordinarily have channeled through a manager were brought instead to our director, placing an even heavier workload on her. The staff members were already accustomed to approaching the CNIVs for most of their day-to-day concerns, and the departmental director became the next person “up the chain” for any problems that the CNIV could not resolve. There were also many positive aspects to management by team that worked well for the staff and department. Although this style initially was a significant adjustment for our unit, the daily operations of the department continued quite smoothly, and we gradually settled into a new equilibrium. Staff seemed to appreciate the cohesiveness of the group and our commitment to maintaining the standards and expectations of the department while we were in flux. We were very touched when they had a CNIV group appreciation day. Our director showed great confidence in our group and encouraged group autonomy; many decisions regarding promotions, tests of change, and staff issues were made with the understanding that at least 3 CNIVs had to agree. Our previous manager would note that 3 CNIVs outranked the manager, and although not a truism, the concept allowed for rapid and cohesive decision making. This experience was tremendously valuable for our professional growth, exposing us to new experiences that we would not otherwise have had the opportunity to try. As a group, we proved quite efficient at shouldering the workload. Rather than passing undesirable tasks off onto the next day’s CNIV, we took pride in looking for opportunities in each day to lighten our coworkers’ loads, pulling an already cohesive group even tighter. We also became better at communicating, running thoughts and ideas past the group, and gaining insight from others. Sharing the workload spared any one person from carrying the burden alone and decreased the risk of burnout. This management experience also gave us a unique opportunity for frequent face-to-face interaction with our director, a circumstance that is typically rare for CNIVs in our unit. The time we spent working closely with our director has allowed us to come to know her well and has rooted in us a deep loyalty and respect. This experience has also increased our confidence, both as individuals and as a group. During this time, we also had an increase in patient satisfaction scores, which we would like to attribute to our management by team and working closely with the
VOLUME 40 • ISSUE 1
January 2014
Braun et al/CLINICAL
ED staff. Comparing July, August, and September 2009 with the same months in 2011, we found an increase in patient’s “would recommend” scores for the emergency department, “courtesy of ED nurses” scores, and “courtesy of ED staff” scores. Although these were not large changes, we were still pleased with this upward trend in scores.
tion skills, abundant leadership experience, and strong selfmotivation. Over the years, our former manager said to us many times, “I’ll know I’ve done my job when you can step in and take over for me.” It was thanks to her years of mentoring and investment in our professional growth that we were ultimately able to fulfill her leadership mission.
Conclusion
REFERENCES
Our new manager has recently started after more than 1 year of team management. We are happy to have her and happily pass back many of the responsibilities we have covered over the last year, allowing us to spend more time with our clinical duties. Our experience has shown us that should we ever face this problem again, we are capable of doing so. At the same time, our experience has given us greater insight into (and respect for) the management of a department of our size and complexity. This has enhanced our ability to do our job and assist our new manager. It has also given us a greater respect and global picture of the department, as well as the workings of the medical center. Although management by team is not a perfect system, it worked well for our department. This is a model that would only work for a group of nurses who, before the management team by trial, already had strong communica-
1. Casida JJ, Pinto-Zipp G. Leadership-organizational culture relationship in nursing units of acute care hospitals. Nurs Econ. 2008;26(1):7-16.
January 2014
VOLUME 40 • ISSUE 1
2. Kenmore P. Exploring leadership styles. Nurs Manag (Harrow). 2008;15 (1):24-6. 3. Raup GH. The impact of ED nurse management leadership style on staff nurse turnover and patient satisfaction in academic health center hospitals. J Emerg Nurs. 2008;34(5):403-9. 4. Barrett L, Ford S, Word-Smith P. A bed management strategy for overcrowding in the emergency department. Nurs Econ. 2012;30 (2):82–85, 116. 5. Institute of Medicine. Hospital Based Emergency Care: At the Breaking Point. Washington DC: National Academics Press; 2006. 6. LaSalle G. Leadership and the emergency department. Emerg Med Clin North Am. 2004;22(1):1-18. 7. Burns JM. Leadership. New York: Harper & Row; 1978. 8. Duygulu S, Kublay G. Transformational leadership training programme for charge nurses. J Adv Nurs. 2010;67(3):633-42. 9. Cook MJ. The renaissance of clinical leadership. Int Nurs Rev. 2001;48 (1):38-46.
WWW.JENONLINE.ORG
59