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Psychiatric-mental health head nurse management concerns
Psychiatric-MentalHealth Head Nurse Management Concerns Janice V.R. Belcher and Barbara Munjas
Psychiatric-mental health head nurses supervise and direct patient care, and therefore, possess a critical, front-line perspective of nursing practice problems. This article explores this perspective by intewiewing four head nurses about patient care, staffing, and organizational management concerns. interestingly, some of the findings of the study, such as head nurse concerns regarding retaining, recruiting, and motivating staff, and increasing patient acuity, already have been supported in the general nursing literature. Other concerns, including the need to clarify the role of the nurse and to define areas of responsibility with other mental health professionals, seem unique to mental health nursing. 0 1990 by W.B. Saunders Company.
A
A NURSING shortage, a decline in nursing school enrollments, and the downward substitution of nurses with variously defined, lower-salaried, less-qualified personnel, psychiatric-mental health nurses and all nurses must critically analyze and dramatically improve nurse practice settings for both the survival and growth of nursing. Nurse researchers perform a vital role in this monumental task and must listen carefully to psychiatric-mental health nurse practitioners and examine their areas of concern. Unless these problem areas are identified and immediately addressed, the current and long-term projected nursing shortage may become catastrophic to mental health care. Since psychiatric-mental health head nurses plan, supervise, and evaluate patient care on a nursing unit, they have a critical, front-line perspective of practice problems. Their managerial perspective is unique because head nurses are responsible for coordinating client, personnel, and organizational needs. Thus, the head nurse’s viewpoint provides invaluable insight into nursing personnel management and client care problems in the psychiatric-mental health nurse’s practice settings. MIDST
From the Medical College of Virginia/Virginia Commonwealth University, Richmond. Address reprint requests to Janice V.R. Belcher, R.N., M.S., Ball State University, Muncie, IN 47306.0265. 0 1990 by W.B. Saunders Company. 0883.9417/90i0404-0005$3,0000/0
260
This article describes an initial exploration of psychiatric-mental health head nurses’ management concerns. Four head nurses were interviewed and the areas of staff, patient care, and organizational management were examined. RELEVANT LITERATURE
The head nurse is the central person responsible for management of patient care, operations, and human resources on a nursing unit (Ganong & Ganong, 1980; Genovich-Richards & Carissimi, 1986). Patient care management includes assessing, planning, implementing, and evaluating patient care; operational management involves scheduling, budgeting, planning, coordinating, and evaluating the performance necessary for organizational operations. Human resource management focuses on the enhancement of staff development (for example, the head nurse may teach continuing education or may counsel employees on possibilities for career mobility [Ganong & Ganong, 1980; Genovich-Richards & Carissimi, 19861). Since the head nurse’s role encompasses patient care as well as staff and organizational management (Ferguson & Brunner, 1982), he or she continually sets priorities for unit, departmental, and organizational objectives and must have strong communication, coordination, and decisionmaking skills (Ferguson & Brunner, 1982). The
Archives of Psychiatric Nursing, Vol. IV, No. 4 (August), 1990: pp. 260-263
HEAD NURSE MANAGEMENT
261
CONCERNS
head nurse’s role is, therefore, a complex one because of the diversity of responsibilities (Miller & Heine, 1988). Due to the continual stress related to the coordination of these diverse areas of responsibility, head nurses can become dissatisfied with their positions. McCausland, Castiglia, and Hunter (1987) surveyed western New York State head nurses, staff nurses, and supervisory nurses for factors causing job dissatisfaction, using a questionnaire in which registered nurses (R.N.s) were asked to rate job satisfaction. Head nurses cited the major cause of stress as inadequate and inappropriate supervision and the next greatest source of stress as inadequate staffing and inadequate or questionable physicians (McCausland et al., 1987, p. 79). The study also found that head nurses “perceived little power in their role and power is essential for leadership” (McCausland et al., 1987, p. 80). Another survey of psychiatric head and charge nurses in England (Vousden, 1985) found that nurse managers felt professionally isolated and requested more professional development. Based on a questionnaire and interview process, the nursing education department created a nurse group for developing support and meeting educational needs. This group was composed of both managerial and educational resources. The nurse managers reported a positive experience in the group (Vousden, 1985). PILOT
Based upon the review of the literature, three areas of psychiatric-mental health head nurse management concerns evolved: (1) staff management, (2) patient care management, and (3) organizational management. In this initial exploration of management concerns, four head nurses were interviewed with the qualitative research method of open-ended questions directed by phenomenology (Knaack, 1984). This type of interview technique was chosen because it allowed head nurses to expand upon topics of their choice, which can lead to a much richer description of their perceived experiences in the managerial role of head nurse (Oiler, 1986). Questions guiding the interview are listed in Table 1. The four head nurses varied in regards to psychiatric-mental health work settings, length of time employed as a head nurse, and educational backgrounds. The four were employed in the following
Table 1. Interview Ouestions What are your concerns as a head nurse? What concerns do you have about your staff? What are your concerns about patient care? In what ways does hospital administrative
structure help or
hinder the resolution of these concerns?
settings: a large, nonprofit general university hospital with two psychiatric units, a small private for-profit pediatric/adolescent psychiatric hospital, a large state psychiatric hospital, and a mediumsized general nonprofit hospital with two psychiatric units that served as the inpatient unit of a community mental health center. The length of time of their employment as a first-line manager ranged from 7 years to 6 months. The head nurses had diverse educational backgrounds consisting of a Master’s of Science degree in psychiatric-mental health nursing, a Bachelor’s of Science degree in nursing, an Associate Degree in nursing, and a Diploma in nursing. STAFF CONCERNS
In the interviews, the head nurses spent more time discussing staffing concerns than they did discussing either patient care or organizational concerns. All head nurses indicated that retention and recruitment of quality staff was a critical problem. This concern is not surprising and is well supported in the nursing literature (Connelly & Strauser, 1983; Curry & Wakefield, 1985; Prescott, 1986; Lowery & Jacobsen, 1984; Hinshaw, 1989). For example, one study conducted among nursing and health administration experts (Henry, Moody, Pendergast , O’Donnell, Hutchinson, & Scully, 1987) concluded that one of the highest nursing administration research priorities should identify ways to increase nurse satisfaction, which is an important component of staff retention. Considering the current magnitude of this problem in practice settings, coupled with the decrease in nursing student admissions, retention and recruitment of competent staff should be a top priority for nursing practice and nursing research. Another major concern was the motivation of staff in their jobs and in the continuation of their education. This concern interrelates with the retention of high-quality staff and with the organizational concerns of improvement of clinical ladder-
262
BELCHER AND MUNJAS
ing with pay differentials and the increase of job satisfaction. The staff nurse position frequently is considered a so-called dead-end job with no opportunity for advancement (Roberts & Fisher, 1988, p. 86). Also, professional nursing autonomy and increasing nursing’s power in the organization is important in the motivation and retention of staff (McCausland et al., 1987). These fundamental issues in nurse employment need to be addressed and corrected in all areas of nursing. One head nurse was concerned about the substitution of R.N.s by lower-salaried, less-qualified personnel and the resultant impact on the quality of nursing care. The head nurse stated that, as the current nursing shortage increases, such substitutions will become more commonplace. One example cited was that of a hospital known to have a shortage of R.N.s. This hospital began by substituting a nurse’s aide for an R.N. on a night shift. The R.N. and the aide subsequently maintained the shift for 6 months. The hospital administration then decided that the aide could permanently replace the R.N. since the cost was less, even though this substitution has a potential impact on the quality of care. This example exemplifies crucial nursing issues surrounding staff substitution, cost effectiveness, and quality of care. One study (Henry et al., 1987) found that cost-effectiveness and quality of care issues should be the first priorities of nursing administration research. For example, researchers could explore the impact of a mental health staff mix on the quality of care as measured by readmission rate and length of hospitalization. ORGANIZATIONAL
CONCERNS
Surprisingly, all head nurses stated that clarifying the role of the psychiatric-mental health nurse with other mental health professionals, including occupational therapists, psychiatrists, social workers, counselors, and psychologists was a major organizational concern. They also stated that there were boundary issues with other disciplines concerning nurse roles versus other mental health worker roles. Other nursing settings, besides that of psychiatric-mental health, may have similar concerns about nursing role clarification, but understanding the role of the nurse seems to be vital for psychiatric-mental health nursing. In this specialty, nurses have many roles that overlap with those of other mental health professionals, and they perform a wide variety of functions, including
group therapy and the counseling of patients and their families. This finding merits further exploration. The two head nurses from larger hospitals were frustrated in their work with nonnursing channels. One nurse manager replied that staff nurses brought in small items for patients because the hospital system could not supply the items efficiently. Another head nurse stated that staff nurses stopped acting on special patient requests, such as special snacks, because of the delayed entanglement within bureaucratic channels, These responses are interesting and suggest further investigation regarding nursing management effectiveness and hospital size. PATIENT CARE CONCERNS
In the area of patient care concerns, there was less consensus among the head nurses, possibly because of the diverse psychiatric-mental health work settings and educational backgrounds of the nurses interviewed. Two of the four nurses stated that the increasing patient acuity was a concern. Increasing acuity is a major issue not only in the psychiatric-mental health nursing, but in all of nursing. This concern has been well documented in the literature, especially with the advent of Diagnostic Related Groups (DRGs) and other financial containments (Hadley and Feder, 1985). In addition to DRGs and financial constraints, psychiatric-mental health patient acuity has also been influenced by less restrictive environment policies and deinstitutionalization policies. The trend toward increased patient acuity promises to continue and to be an acute nursing problem in the future. The increasing number of patients without adequate financial resources for hospitalization was another concern. It is estimated that approximately 28 million Americans have no health insurance and approximately 17 million Americans are underinsured. Of these people, it is estimated that 1 million Americans are denied health care every year and at least 10 million do not even seek the care they need because they cannot afford the care (Senate Bill, S1256, 1987). Another factor contributing to the lack of financial resources is the reduction of insurance benefits for mental health services. A lack of financial resources may contribute to patients’ delay of treatment, thus increasing patient acuity and chronicity. Head nurses also were concerned about their
HEAD NURSE MANAGEMENT
CONCERNS
staff’s ability to provide adequate discharge planning for patients. Planning becomes increasingly important when patients have more financial constraints, leading to earlier discharges. One head nurse also was concerned about the lengthy waiting period for long-term placement and stated that the lack of community placement facilities often contributed to an extended length of stay in the hospital. Supporting chronic psychiatric patients in the community was another concern. This concern is reflected in the literature as a prevalent psychiatricmental health problem (Geller, 1986; Harris, Bergman & Bachrach, 1986). Recidivism is part of the problem of supporting chronic psychiatric patients in the community. Patients need adequate and available resources in the community in order to remain in the community. CONCLUSION
This initial exploration of head nurse management concerns should be continued and expanded since it generates many research questions. Staffing concerns such as recruiting, retaining, and motivating staff should be further explored. Nursing should create and test clinical ladders and other innovations for increased nurse satisfaction, which will lead to the retention of competent staff. In the area of organizational concerns, psychiatricmental health nursing should continue to clarify the role of the nurse with other mental health professionals. In addition, patient acuity, inadequate financial coverage, and adequate discharge planning are vital patient care research areas. Since the head nurse is the central nurse responsible for patient care, staffing, and organizational management on a nursing unit, this first-line manager provides invaluable insight into the nursing problems that are crucial for psychiatric-mental health nursing’s survival and growth. REFERENCES Connelly, J., & Strauser, K. (1983). Managing recruitment and retention problems: An application of the marketing
263
process. The Journal of Nursing Administration, (10). 17-22. Curry, J.P., Wakefield, D.S., Price, J.L., Mueller. C. W., & McCloskey, J.C. (1985). Determinants of turnover among nursing department employees. Research in Nursing & Health, 8(4), 397-411. Ferguson, D.L., & Brunner. N.A. (1982). Balancing priorities to attain quality care. Nursing Management, IjrClO). 67-69. Ganong, J.M., & Ganong, W .L. (1980). Nursing management, (2nd ed.). Rockville, MD: Aspen Systems. Geller, J.L. (1986). In again, out again: Preliminary evaluation of a state hospital’s worst recidivists. Hospital and Community Psychiatry, 37(6), 630-631. Genovich-Richards, J., & Carissimi, D.C. (1986). Developing nurses’ managerial competence. Nursing Management, 17(3), 36-38. Hadley, J., & Feder, J. (1985). Hospital cost shifting and care for the uninsured. Health Affairs, Fall. Harris, M., Bergam, H.C., & Bachrach, L.L. (1986). Psychiatric and nonpsychiatric indicators for rehospitalized in a chronic patient population. Hospital and Community Psychiatry. 37(6), 201-209. Hem-y, B., Moody, L.E., Pendergast, J.F., O’Donnell. J.. Hutchinson, S.A., & Scully, G. (1987). Delineation of nursing administration research priorities. Nursing Research, 36(5), 309-3 13. Hinshaw, A.S. (1989). Programs of nursing research for nursing administration. In Dimensions of nursing administration. Boston, MA: Blackwell. Knaack, P. (1984). Phenomenological research. Western Journal of Nursing Research, 6(l). 107-I 14. Lowery, B.J., & Jacobsen, B.S. (1984). On the consequences of overturning turnover: A study of performance and turnover. Nursing Research, 33(6), 363-367. McCausland. L., Castiglia, P.T., & Hunter. J.H. ( 1987). Nursing Management, 18(6), 79-80. Miller, M.M., & Heine. C. (1988). The complex role of the head nurse. Nursing Management, 19(6), 58-64. Minimum health benefits act of 1987. (Senate Bill. S 1256). (Report No. 100-132). 100th Congress. Oiler, C.J. (1986). Phenomenology: The method. In Munhall, P.L. and Oiler, C.J., (Eds.). Nursing research: A qualitative perspective. Norwalk, CT: Appleton-CenturyCroft Prescott, P. (1986). Vacancy, stability, and turnover of registered nurses in hospitals. Research in Nursing and Health, 9(l), 51-60. Roberts, M.T., & Fisher, M.L. (1988). Establishing a clinical ladder: The process. Nursing Management, 19(5). p. 88. Vousden, M. (1985). Taking the strain. Nursing Mirror, 161(7), 25-27.
Psychiatric-mental health head nurses supervise and direct patient care, and therefore, possess a critical, front-line perspective of nursing practice problems. This article explores this perspective by intewiewing four head nurses about patient care, staffing, and organizational management concerns. interestingly, some of the findings of the study, such as head nurse concerns regarding retaining, recruiting, and motivating staff, and increasing patient acuity, already have been supported in the general nursing literature. Other concerns, including the need to clarify the role of the nurse and to define areas of responsibility with other mental health professionals, seem unique to mental health nursing. 0 1990 by W.B. Saunders Company.
A
A NURSING shortage, a decline in nursing school enrollments, and the downward substitution of nurses with variously defined, lower-salaried, less-qualified personnel, psychiatric-mental health nurses and all nurses must critically analyze and dramatically improve nurse practice settings for both the survival and growth of nursing. Nurse researchers perform a vital role in this monumental task and must listen carefully to psychiatric-mental health nurse practitioners and examine their areas of concern. Unless these problem areas are identified and immediately addressed, the current and long-term projected nursing shortage may become catastrophic to mental health care. Since psychiatric-mental health head nurses plan, supervise, and evaluate patient care on a nursing unit, they have a critical, front-line perspective of practice problems. Their managerial perspective is unique because head nurses are responsible for coordinating client, personnel, and organizational needs. Thus, the head nurse’s viewpoint provides invaluable insight into nursing personnel management and client care problems in the psychiatric-mental health nurse’s practice settings. MIDST
From the Medical College of Virginia/Virginia Commonwealth University, Richmond. Address reprint requests to Janice V.R. Belcher, R.N., M.S., Ball State University, Muncie, IN 47306.0265. 0 1990 by W.B. Saunders Company. 0883.9417/90i0404-0005$3,0000/0
260
This article describes an initial exploration of psychiatric-mental health head nurses’ management concerns. Four head nurses were interviewed and the areas of staff, patient care, and organizational management were examined. RELEVANT LITERATURE
The head nurse is the central person responsible for management of patient care, operations, and human resources on a nursing unit (Ganong & Ganong, 1980; Genovich-Richards & Carissimi, 1986). Patient care management includes assessing, planning, implementing, and evaluating patient care; operational management involves scheduling, budgeting, planning, coordinating, and evaluating the performance necessary for organizational operations. Human resource management focuses on the enhancement of staff development (for example, the head nurse may teach continuing education or may counsel employees on possibilities for career mobility [Ganong & Ganong, 1980; Genovich-Richards & Carissimi, 19861). Since the head nurse’s role encompasses patient care as well as staff and organizational management (Ferguson & Brunner, 1982), he or she continually sets priorities for unit, departmental, and organizational objectives and must have strong communication, coordination, and decisionmaking skills (Ferguson & Brunner, 1982). The
Archives of Psychiatric Nursing, Vol. IV, No. 4 (August), 1990: pp. 260-263
HEAD NURSE MANAGEMENT
261
CONCERNS
head nurse’s role is, therefore, a complex one because of the diversity of responsibilities (Miller & Heine, 1988). Due to the continual stress related to the coordination of these diverse areas of responsibility, head nurses can become dissatisfied with their positions. McCausland, Castiglia, and Hunter (1987) surveyed western New York State head nurses, staff nurses, and supervisory nurses for factors causing job dissatisfaction, using a questionnaire in which registered nurses (R.N.s) were asked to rate job satisfaction. Head nurses cited the major cause of stress as inadequate and inappropriate supervision and the next greatest source of stress as inadequate staffing and inadequate or questionable physicians (McCausland et al., 1987, p. 79). The study also found that head nurses “perceived little power in their role and power is essential for leadership” (McCausland et al., 1987, p. 80). Another survey of psychiatric head and charge nurses in England (Vousden, 1985) found that nurse managers felt professionally isolated and requested more professional development. Based on a questionnaire and interview process, the nursing education department created a nurse group for developing support and meeting educational needs. This group was composed of both managerial and educational resources. The nurse managers reported a positive experience in the group (Vousden, 1985). PILOT
Based upon the review of the literature, three areas of psychiatric-mental health head nurse management concerns evolved: (1) staff management, (2) patient care management, and (3) organizational management. In this initial exploration of management concerns, four head nurses were interviewed with the qualitative research method of open-ended questions directed by phenomenology (Knaack, 1984). This type of interview technique was chosen because it allowed head nurses to expand upon topics of their choice, which can lead to a much richer description of their perceived experiences in the managerial role of head nurse (Oiler, 1986). Questions guiding the interview are listed in Table 1. The four head nurses varied in regards to psychiatric-mental health work settings, length of time employed as a head nurse, and educational backgrounds. The four were employed in the following
Table 1. Interview Ouestions What are your concerns as a head nurse? What concerns do you have about your staff? What are your concerns about patient care? In what ways does hospital administrative
structure help or
hinder the resolution of these concerns?
settings: a large, nonprofit general university hospital with two psychiatric units, a small private for-profit pediatric/adolescent psychiatric hospital, a large state psychiatric hospital, and a mediumsized general nonprofit hospital with two psychiatric units that served as the inpatient unit of a community mental health center. The length of time of their employment as a first-line manager ranged from 7 years to 6 months. The head nurses had diverse educational backgrounds consisting of a Master’s of Science degree in psychiatric-mental health nursing, a Bachelor’s of Science degree in nursing, an Associate Degree in nursing, and a Diploma in nursing. STAFF CONCERNS
In the interviews, the head nurses spent more time discussing staffing concerns than they did discussing either patient care or organizational concerns. All head nurses indicated that retention and recruitment of quality staff was a critical problem. This concern is not surprising and is well supported in the nursing literature (Connelly & Strauser, 1983; Curry & Wakefield, 1985; Prescott, 1986; Lowery & Jacobsen, 1984; Hinshaw, 1989). For example, one study conducted among nursing and health administration experts (Henry, Moody, Pendergast , O’Donnell, Hutchinson, & Scully, 1987) concluded that one of the highest nursing administration research priorities should identify ways to increase nurse satisfaction, which is an important component of staff retention. Considering the current magnitude of this problem in practice settings, coupled with the decrease in nursing student admissions, retention and recruitment of competent staff should be a top priority for nursing practice and nursing research. Another major concern was the motivation of staff in their jobs and in the continuation of their education. This concern interrelates with the retention of high-quality staff and with the organizational concerns of improvement of clinical ladder-
262
BELCHER AND MUNJAS
ing with pay differentials and the increase of job satisfaction. The staff nurse position frequently is considered a so-called dead-end job with no opportunity for advancement (Roberts & Fisher, 1988, p. 86). Also, professional nursing autonomy and increasing nursing’s power in the organization is important in the motivation and retention of staff (McCausland et al., 1987). These fundamental issues in nurse employment need to be addressed and corrected in all areas of nursing. One head nurse was concerned about the substitution of R.N.s by lower-salaried, less-qualified personnel and the resultant impact on the quality of nursing care. The head nurse stated that, as the current nursing shortage increases, such substitutions will become more commonplace. One example cited was that of a hospital known to have a shortage of R.N.s. This hospital began by substituting a nurse’s aide for an R.N. on a night shift. The R.N. and the aide subsequently maintained the shift for 6 months. The hospital administration then decided that the aide could permanently replace the R.N. since the cost was less, even though this substitution has a potential impact on the quality of care. This example exemplifies crucial nursing issues surrounding staff substitution, cost effectiveness, and quality of care. One study (Henry et al., 1987) found that cost-effectiveness and quality of care issues should be the first priorities of nursing administration research. For example, researchers could explore the impact of a mental health staff mix on the quality of care as measured by readmission rate and length of hospitalization. ORGANIZATIONAL
CONCERNS
Surprisingly, all head nurses stated that clarifying the role of the psychiatric-mental health nurse with other mental health professionals, including occupational therapists, psychiatrists, social workers, counselors, and psychologists was a major organizational concern. They also stated that there were boundary issues with other disciplines concerning nurse roles versus other mental health worker roles. Other nursing settings, besides that of psychiatric-mental health, may have similar concerns about nursing role clarification, but understanding the role of the nurse seems to be vital for psychiatric-mental health nursing. In this specialty, nurses have many roles that overlap with those of other mental health professionals, and they perform a wide variety of functions, including
group therapy and the counseling of patients and their families. This finding merits further exploration. The two head nurses from larger hospitals were frustrated in their work with nonnursing channels. One nurse manager replied that staff nurses brought in small items for patients because the hospital system could not supply the items efficiently. Another head nurse stated that staff nurses stopped acting on special patient requests, such as special snacks, because of the delayed entanglement within bureaucratic channels, These responses are interesting and suggest further investigation regarding nursing management effectiveness and hospital size. PATIENT CARE CONCERNS
In the area of patient care concerns, there was less consensus among the head nurses, possibly because of the diverse psychiatric-mental health work settings and educational backgrounds of the nurses interviewed. Two of the four nurses stated that the increasing patient acuity was a concern. Increasing acuity is a major issue not only in the psychiatric-mental health nursing, but in all of nursing. This concern has been well documented in the literature, especially with the advent of Diagnostic Related Groups (DRGs) and other financial containments (Hadley and Feder, 1985). In addition to DRGs and financial constraints, psychiatric-mental health patient acuity has also been influenced by less restrictive environment policies and deinstitutionalization policies. The trend toward increased patient acuity promises to continue and to be an acute nursing problem in the future. The increasing number of patients without adequate financial resources for hospitalization was another concern. It is estimated that approximately 28 million Americans have no health insurance and approximately 17 million Americans are underinsured. Of these people, it is estimated that 1 million Americans are denied health care every year and at least 10 million do not even seek the care they need because they cannot afford the care (Senate Bill, S1256, 1987). Another factor contributing to the lack of financial resources is the reduction of insurance benefits for mental health services. A lack of financial resources may contribute to patients’ delay of treatment, thus increasing patient acuity and chronicity. Head nurses also were concerned about their
HEAD NURSE MANAGEMENT
CONCERNS
staff’s ability to provide adequate discharge planning for patients. Planning becomes increasingly important when patients have more financial constraints, leading to earlier discharges. One head nurse also was concerned about the lengthy waiting period for long-term placement and stated that the lack of community placement facilities often contributed to an extended length of stay in the hospital. Supporting chronic psychiatric patients in the community was another concern. This concern is reflected in the literature as a prevalent psychiatricmental health problem (Geller, 1986; Harris, Bergman & Bachrach, 1986). Recidivism is part of the problem of supporting chronic psychiatric patients in the community. Patients need adequate and available resources in the community in order to remain in the community. CONCLUSION
This initial exploration of head nurse management concerns should be continued and expanded since it generates many research questions. Staffing concerns such as recruiting, retaining, and motivating staff should be further explored. Nursing should create and test clinical ladders and other innovations for increased nurse satisfaction, which will lead to the retention of competent staff. In the area of organizational concerns, psychiatricmental health nursing should continue to clarify the role of the nurse with other mental health professionals. In addition, patient acuity, inadequate financial coverage, and adequate discharge planning are vital patient care research areas. Since the head nurse is the central nurse responsible for patient care, staffing, and organizational management on a nursing unit, this first-line manager provides invaluable insight into the nursing problems that are crucial for psychiatric-mental health nursing’s survival and growth. REFERENCES Connelly, J., & Strauser, K. (1983). Managing recruitment and retention problems: An application of the marketing
263
process. The Journal of Nursing Administration, (10). 17-22. Curry, J.P., Wakefield, D.S., Price, J.L., Mueller. C. W., & McCloskey, J.C. (1985). Determinants of turnover among nursing department employees. Research in Nursing & Health, 8(4), 397-411. Ferguson, D.L., & Brunner. N.A. (1982). Balancing priorities to attain quality care. Nursing Management, IjrClO). 67-69. Ganong, J.M., & Ganong, W .L. (1980). Nursing management, (2nd ed.). Rockville, MD: Aspen Systems. Geller, J.L. (1986). In again, out again: Preliminary evaluation of a state hospital’s worst recidivists. Hospital and Community Psychiatry, 37(6), 630-631. Genovich-Richards, J., & Carissimi, D.C. (1986). Developing nurses’ managerial competence. Nursing Management, 17(3), 36-38. Hadley, J., & Feder, J. (1985). Hospital cost shifting and care for the uninsured. Health Affairs, Fall. Harris, M., Bergam, H.C., & Bachrach, L.L. (1986). Psychiatric and nonpsychiatric indicators for rehospitalized in a chronic patient population. Hospital and Community Psychiatry. 37(6), 201-209. Hem-y, B., Moody, L.E., Pendergast, J.F., O’Donnell. J.. Hutchinson, S.A., & Scully, G. (1987). Delineation of nursing administration research priorities. Nursing Research, 36(5), 309-3 13. Hinshaw, A.S. (1989). Programs of nursing research for nursing administration. In Dimensions of nursing administration. Boston, MA: Blackwell. Knaack, P. (1984). Phenomenological research. Western Journal of Nursing Research, 6(l). 107-I 14. Lowery, B.J., & Jacobsen, B.S. (1984). On the consequences of overturning turnover: A study of performance and turnover. Nursing Research, 33(6), 363-367. McCausland. L., Castiglia, P.T., & Hunter. J.H. ( 1987). Nursing Management, 18(6), 79-80. Miller, M.M., & Heine. C. (1988). The complex role of the head nurse. Nursing Management, 19(6), 58-64. Minimum health benefits act of 1987. (Senate Bill. S 1256). (Report No. 100-132). 100th Congress. Oiler, C.J. (1986). Phenomenology: The method. In Munhall, P.L. and Oiler, C.J., (Eds.). Nursing research: A qualitative perspective. Norwalk, CT: Appleton-CenturyCroft Prescott, P. (1986). Vacancy, stability, and turnover of registered nurses in hospitals. Research in Nursing and Health, 9(l), 51-60. Roberts, M.T., & Fisher, M.L. (1988). Establishing a clinical ladder: The process. Nursing Management, 19(5). p. 88. Vousden, M. (1985). Taking the strain. Nursing Mirror, 161(7), 25-27.