Managing the Managers

Dear Director,
I think my nurse manager is ineffective and has lost the support of the ED staff. She doesn’t report to me. How involved should I get in the nursing business?
Signed,
F.B., MD

Diagnosing the Problem: Where is the Actual Deficiency?
The first step is recognizing the importance of solid nursing leadership to the success of your department. As you no doubt realize, there is a special relationship between the physician and nurse leaders of an ED ­­– in the best-case scenario, they work together to create and implement a vision. Almost every activity in the ED requires physician and nursing collaboration (the metric might be “Door-to-Doc,” but clearly the triage and charge nurse play a huge role in achieving this goal). Once you’ve come to understand how essential your nursing leadership is, your next step is to define the deficiencies that exist and find out how you can help the situation.

I have found, over the years, that complaints about nurse managers have some of the same general themes as are heard with medical directors. I’ve heard nurses complain about their manager’s lack of connecting to the staff on a clinical level, not responding to staff issues in a timely fashion and being unable to recruit, retain, or terminate people effectively. Your experience as a physician leader should provide some credibility when offering advice to your nurse manager. However, tread lightly; your well-intentioned offer to remediate may be taken as the beginning of an attempted coup.

One symptom of an ineffective nurse manager may be that you’re meeting with the nursing staff on a regular basis, instead of their manager. Attending charge nurse and ED staff meetings occasionally is great. But, running them on a monthly basis begs the question of why are you doing the nurse manager’s job, which may undermine their credibility. The nurse manager needs to be engaged with their staff, aware of their issues and able to interact effectively.

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Staff become very dissatisfied when their requests are not being met by management. This doesn’t mean we need to roll over, buy pizza every day and throw extra staff into the mix, but it does mean that the nurse manager needs to go to bat for their team (and occasionally hit a home run) being a champion for patient safety and quality of care. A dissatisfied staff will lead to dissatisfied patients and likely a dissatisfied physician staff. Getting the ship steered in the right direction with the staff being on board with the department’s goals can strengthen the nurse manager’s position within the department.

Just like the physician team is built on the foundation of recruitment and retention, the nurse manager needs to be able to sell the program to attract the best candidates, fill the holes and retain good nurses. While it is typically not the medical director’s job to interview for nursing vacancies, if recruitment is one of the nurse manager’s problems, the medical director may assist by coaching the nurse manager on successful interviewing techniques.

I’ve frequently heard that the staff wants the nurse manager to help them clinically in times of high volumes. What is essential here is that the nurse manager be able to communicate the importance of the behind-the-scenes work taking place. Certainly, having an extra nurse might be nice, but unless there’s a disaster, this is probably not the best use of the nurse manager’s time. When staff nurses bring such a complaint to you, this gives you an opportunity to help explain how the nurse manager needs to be keeping their head up, focusing on the department’s vision and preventing the next problem, rather than putting their head down to start an IV. You can set the expectation for the staff that the nurse manager is a resource and a teacher but not a staffing solution.

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Pulling the Trigger: Put the Patients First
If mentoring strategies don’t do the trick, it’s time to talk to the nurse manager’s boss or the CNO. This level of interference outside of our hierarchy and comfort zone will depend on your relationship with the hospital’s executive physician and nursing leadership. How much political capital do you have within the hospital, and how much are you willing to spend? Remember, if the CNO makes a change based on your interaction, 1) you’ll likely be without a nurse manager for at least some period of time, 2) you’ll be left carrying the extra weight of leading the nurses through this transition, and 3) if the CNO doesn’t agree with you or is unwilling to make a change, you’ve left yourself exposed, potentially with a nurse manager as an enemy and you could even risk your own position. If you put the patients first, you’ll make a stronger case for a needed change in the nurse manager’s performance or a new nurse manager altogether.

Ultimately, leaders need to create and implement a vision. Nurses and physicians have different job responsibilities and typically report to different people, but we are clearly dependent upon each other to achieve success. Recognizing a deficiency in this relationship can hopefully be overcome with mentoring, but if that doesn’t work, hospital politics not withstanding, don’t be afraid to go to the top to do what’s best for the department and the patients.