Dear Director: My nurse manager and I can’t see eye to eye on how to get things done. Can I just work on my own agenda and let her worry about her issues or can you suggest some strategies that will help us work together?
In most EDs, nursing and physician managers/leaders operate in different silos. Often, we don’t report to the same hospital administrator and while we each have our own vision, objectives and goals, they may not be aligned.
Historically, the chair’s job (and the contract if you’re a contracted physician) was considered most at risk every time the hospital got a new CEO. This change in hospital leadership meant you were interviewing for your job all over again. Given that hospitals may change CEOs every 3.5 to 5.5 years, it’s no wonder ED chairs often don’t feel like they have job security [1,2]. Given the importance of ED metrics in publicly reported measures, and that ED nurse managers frequently have the ear of the chief nursing officer (CNO), now more than ever, it’s critical that the ED chair also have the support of the nurse manager.
(Because rank and title may differ from ED to ED, for the purposes of this article, nurse manager and director should be considered synonymous and refer to the senior nurse who is responsible for running the day to day ED operations. This person may report to a hospital VP or the CNO).
I’ve been blessed to work alongside excellent nurse leaders in my EDs who I’ve gotten along with personally and professionally. But many of my friends and colleagues have not been as lucky. Relationships can take three paths in my mind. You and the nurse manager can be going the same direction and on the same bus and be successful. You can be in separate buses going parallel together but not talking to each other and it will be hard to achieve success as you work independently on your personal agenda. Or your relationship can be so toxic you’re about to T-bone each other and cause a massive back up on the freeway.
While providing exceptional quality of care may be one of your key interests, everyone involved in ED administration is attached to metrics in one way or another. As we transition to a new year, now is an excellent time to sit down with nursing leadership and review each of your goals. Whether it’s focusing on the same three goals and having similar success thresholds, metric based goals need to be aligned between the docs and nursing staff. Put them all out on the table along with who is requesting it (CEO, CNO, contract management group) and then see where the common ground is and where the needle needs to be moved. Working in the ED has always been considered a team sport, and the management arena is no exception. Once you both understand what the goals are, then you can strategize together about how each team (docs, nurses) can help each other. Besides the pride you can take in accomplishing your goals, the incentive should be obvious since you both likely have bonus money tied up in achieving these goals.
It’s not as easy to work with someone we don’t like but the reality is that we don’t have to like everyone we work with. However, we do need to communicate and work together if the job requires it. Communication is the key to building relationships and who knows, with enough time spent working together, and perhaps sharing a meal or coffee break together, maybe you’ll start to like each other more.
Most directors I know have a scheduled 1:1 meeting with their nurse manager weekly. Alternatively, if you communicate well, are flexible, and your schedules allow it, having an open door policy or having frequent, short, on-the-run meetings to touch base on key issues can work. I’ve done both. I like touching base regularly throughout the day or week (both people need to keep lists so you’re not forgetting what’s important), but it’s also important to have regular discussions about the big picture and strategic plans, otherwise, the daily contacts are spent putting out fires and not planning.
The scheduled meetings are a great opportunity to discuss priorities and objectives. Both directors (nursing and physician) need to discuss and understand how each group impacts the other’s priorities and end results. Just like you’ll ask your CEO what you can do for them, you should also ask your nurse manager how you, and the docs, could help. You may be surprised what you hear. One of the most frequent requests I’ve gotten from nurse managers is to help provide education to the nursing staff. This could be a “medical minute” at the shift-change huddle or a 10-20 minute mini-lecture at a nurse staff meeting. And while it can be a great opportunity for you to get up in front of the nursing staff, it can also be an opportunity to let one of your other docs get involved. Common themes for education include EKG interpretation, emergency hypertension management, sepsis management, and anything tox related. Proper “clicking” on your EMR (when we’re in the room, when we’re ready for the patient to be discharged, etc.) is another frequent conversation. Getting our docs to understand how the “clicks” impact the nurse metrics is usually underrated by us, and “unrealistic clicking” frustrates nursing.
Like we do with so many other colleagues, meetings are not confined to face to face in the hospital. I suspect if you’re not texting your nurse manager or having cell phone conversations, you’re probably not talking enough. While the nurse manager probably works fairly typical hospital hours, we’re ER docs and probably don’t. However, we still need to be in touch. Washington DC traffic is as bad as everyone says and I have a long commute. But, whether I’m coming or going to the hospital, it’s a great opportunity to catch up with my manager and recap the day.
Once you and nursing develop joint goals, the next step is to have a joint message that can be communicated to the C-suite. Before every meeting I have with my CEO, I sit with my nurse manager to discuss my talking points. Obviously, I have my own objectives with the CEO, but when it comes to explaining the EDs performance or our current top issues, my nurse manager and I need to be on the same page. If I’m going to be critical of nursing (staffing is not an uncommon topic for any ED I know), it’s not just common courtesy to let the nurse manager know. It helps to keep our messaging the same—i.e. why is there a nurse shortage, what are the pro’s and con’s of agency use, how can we supplement staff with techs. My job is to understand the root cause of the nursing issues so that I can present and discuss them with the CEO. After the meeting, we debrief as well. It’s important that I let her know if any other nursing topics came up in the meeting (regardless of who brings it up). As tempting as it is to blame nursing for any metric related deficiencies, and throw them under the bus, this will only bring irreparable harm to your relationship. You can’t have an “us versus them” mentality but rather, you need to be prepared to stand united with your nursing teammate, recognizing that the ED is the “us” and the physician and nursing director are seen as leading the ED together. And there is a very fine line when discussing nursing issues without your nurse manager in the room. It’s going to happen and you should be prepared to answer in the same way you would if your nurse manager was in the room. With enough honesty during the debrief, you will gain the trust of your nurse manager. This will pay dividends in each of your interactions with the C-suite, but will also pay off in other ways as well. For example, if your relationship is strained, that negative interaction between the nurse and night shift doc might escalate to the CNO or CMO very quickly. But with trust and communication, you’ve each earned the opportunity to manage your team, keeping problems within the family, or the walls of the ED.
Making sure your C-suite messaging is consistent is just the first step of the united front. The next step is to make sure you’re unified in your messages to your respective groups. There’s a few ways to accomplish this. The first step is to attend the other’s staff meeting and have a standing spot on the agenda. If time is our most precious commodity, giving time to support the other and be available to the staff is an excellent opportunity to show commitment to the department. I have very few secrets from my nurse manager. I cc her on essentially every email I send to my group. She does the same. We each recognize that we need to be aware of how the messages are being delivered and also aware of what the message is. From time to time, we also send out joint emails to our staffs so that all of the department’s caregivers see us as being on the same page. One of the great opportunities to bond and form your united front in by attending a conference together. Sitting together during lectures and meals for a day or two should certainly generate some ideas and discussions that can be brought back to the ED.
The ED chair job is very challenging. It’s hard for me to imagine being successful without having an excellent working relationship with the nurse manager. This relationship needs to cultivated with frequent communication, aligning goals, and actively trying to help each other be successful. Failure to manage this relationship can also have negative consequences for you.