Question and Answer about Time Management

September 13, 2007

A member asks one of the most common questions we get:

My most pressing question is how to manage tasks. I find myself putting out fires all day and getting behind on issues that are part of my role. I have been a Nurse Manager for a year now with training that can be labeled as a baptism by fire. I want to do a great job though. There was no one to show me the ropes. Actually I got the job due to being the go to person for the surgical area. So, when the management position was established, I was the unit expert and got the job. The previous manager also had the operating room and PACU, so when the surgical clinics and specialties were taken from her supervision, she never looked back.

Is there a way to manage the daily fire fighting and get required tasks accomplished? I supervise Surgical Clinics, Podiatry, ENT, Neurology, Rheumatology, Cardiology, Urology, and Ophthalmology.

Our brief answer (and of course we go into more details about Time Management in our program):

Time Management is a huge challenge for Nurse Managers and so we empathize with you. That’s because most Nurse Managers have more tasks than time available (unless they want no personal or family life). So you have to ask what the 20% of things are that get you 80% of your results in terms of quality and productivity, and make those always come first. The other 80% are where you have to make some decisions, delegate, set priorities, or just say no.

The following exercise might help you. For about a week, write down how you spend your time in 15 min increments.

Then analyze according to the following questions:

1. Did anyone have to do this task at all?

2. Did I have to do it or could someone else have done it? For instance, do I really need to go to all of those meetings or can someone else go and brief me later?

3. Did I have to do it now or could it have waited?

4. Are my standards too high? Can I do less and get an acceptable result? Can I make decisions more rapidly and with the information available?

5. Going forward, can I set aside specific time to group certain tasks and be more efficient (like setting aside an hour long block for people to ask questions, rather than tolerating constant interruptions — excepting TRUE emergencies of course)?

6. For which tasks do I need to set boundaries or negotiate with someone to let them know that I can either do those tasks or another set of tasks, but don’t have the time to do both?

7. On which tasks can I be more efficient, for instance by scanning journal articles rather than saving and trying to read the entire journal?

Based on your above answers, try to schedule your day more efficiently and proactively. For instance, set aside schedule blocks where you are walking around, where your office is open for questions, where you are delegating more tasks to others, and where you are in closed door work doing admin things.

How to set the appropriate tone on your unit

July 23, 2007

One of the most important roles of the Nurse Manager is setting the appropriate tone on her unit. This means taking 100% accountability for the quality, productivity, service, and employee retention/satisfaction on the unit.

In our experience, many Nurse Managers fail to set the appropriate tone. For instance, we recently worked with one organization in which some nursing units were in the bottom 25th percentile in patient satisfaction via Press Gainey surveys. The reaction of the Nurse Managers responsible for these results: “It’s on our list and we will begin addressing this within the next six months. Our goal is to get to the 50th percentile within a year.”

We hope you agree that this reaction is unacceptable!

The most successful Nurse Managers have, and create, a sense of urgency. They acknowledge what is working on their units, but also look for opportunities to improve. If something related to compliance, patient safety, or patient satisfaction is out of whack, they immediately take steps to get back on track. Immediately! (This doesn’t mean that the Nurse Manager makes rash decisions. She uses the data she has to set the most appropriate course to get back on track as quickly as possible).

In our judgment 50th percentile is simply not good enough, not even close. EVERY Nurse Manager should be aiming for at least the top 25th percentile in quality, productivity, and service — if not the top 5th percentile.

In the way she carries herself, the questions she asks, the compliments she gives, the challenges she sets, what she measures, and where she spends her time, the Nurse Manager sets the tone on her unit.

We recently held a seminar of both new and seasoned Nurse Managers. The Nurse Manager who stood out the most was a young woman who had just stepped into her role. During a case study, we gave an example of a situation in which the Nurse Manager needed to set an ambitious goal on her unit. While other Nurse Managers in the group seemed a bit hesitant, even tentative about setting such an ambitious goal, this newer professional showed confidence and personal power. She said, in a commanding and confident — but not obnoxious or overbearing way — “I know my staff will reach this goal because I’m not going to tolerate anything less from them.” When we heard her words, we could tell based on her tone that she would succeed.

Meanwhile, we got the sense that the other participants were choosing to be popular with their staff, and to encourage harmony, rather than on getting results. The best Nurse Managers balance both relationships and results. They neither avoid difficult conversations nor have to coerce/force their way to results. They achieve results through strong alliances based on mutual respect, personal leadership and commitment, and critical thinking skills.

When we lead seminars, the first thing we do is challenge Nurse Managers to decide whether the role of manager is right for them. If you aren’t comfortable setting a tone of excellence and urgency on your unit, then you might consider whether Nurse Management is for you.

Observations during the kickoff retreat of a Nurse Manager Leadership University

June 6, 2007

We recently returned from leading a Nurse Manager Leadership kick off meeting, the first stage in a year-long Nurse Manager Leadership University at a large hospital. This was a three-day retreat that included the Nursing Management group of the hospital (done in two back-to-back session to handle the large class size).

What we observed is not so different than what we see at many hospitals.

1. While the Nurse Manager is the most important role in the hospital, setting the tone for quality of care on the unit and serving as the determining factor in retention of staff, she is rarely recognized as such. The participants in this class were thrilled that the hospital was finally focusing on their professional development as a priority.

2. Many Nurse Managers do not take 100% accountability for what happens on their unit. Nurse Managers are in a difficult position. They have 100% accountability for the quality, productivity, and service on the unit — but not 100% authority. Still, the top Nurse Managers take full accountability for setting the tone on the unit and for the outcomes that the unit achieves.

3. Silos in hospitals are created by language and perceptions. By the end of the retreat, Nurse Managers recognized that the silos are not “out there” but rather that they have a role in creating silos through poor communication and relationship building. In fact, they acknowledged the silos on their own unit, especially between shifts.

4. There is often great distrust up, down, and across the organization. Nurse Managers are the sandwich meat between two slices of bread — the executive team and care staff. More than any other role, they can serve as the bridge that builds trust and alignment throughout the organization.

5. While Nurse Managers expressed familiarity with performance improvement and budgeting tools, case studies with those tools revealed that one can always deepen their understanding. Beginning and professional tennis players both practice the forehand, and beginning and seasoned managers alike can practice their problem solving skills.

6. Nurse Managers can develop improved flexibility in situational management as well as in the style and strategies they use to influence others authentically and build relationships. Many managers reported that they had never before rehearsed crucial conversations in a safe setting, and that taking time to plan for challenging situations was extremely valuable.

7. Nurse Managers really benefit from setting up a support network. Our Leadership University sets up a safe support network to discuss and resolve challenges, and help managers rejuvenate.

8. Many Nurse Managers lack a broad understanding of the hospital system and the goals/vision of the key leaders. For this reason, future sessions will include “senior leadership rounds” and town-hall style, intimate meetings with board members and executives.

9. Nurse Managers get what they tolerate. If outcomes on a unit are poor, it is almost always because the Nurse Manager tolerates those results, and by default, condones them.

At the end of the retreat, participants chose three goals that will be the focus of their yearlong participation: an individual/professional development goal; a unit goal; and a hospital-wide goal. That way, the university becomes practical and we focus on real-time issues. Participants appreciated time to step back and focus on their most important goals, without worrying about fighting fires.

Being honest about your leadership capabilities

April 30, 2007

Here are some observations while we implement our Nurse Leadership Academy at a  well-respected regional hospital:

1. Many Nurse Managers have not successfully made the leap from staff nurse to management. These managers still commiserate too much with staff, even thinking of staff as “buddies.” Once you become a manager, you must forget about being popular. Rather,  you have to set high standards for your unit and mobilize your staff to go the extra mile to achieve those standards — while being fair with each staff member, letting them know how they are doing (and how they can do better), and being concerned about their ongoing development and success.

2. Some Nurse Managers actually sabotage the organization that has promoted them and pays them. For instance, they sometimes complain to medical staff about issues and enlist the medical staff to argue for them, rather than going to their direct supervisor and making a case for change. This “end around” undermines leadership’s credibility with the medical staff, and the manager’s credibility with leadership. Nobody wins.

3. Many Nurse Managers have an opportunity to claim their place at the table as managers and leaders. We work with a number of hospitals where Nurse Managers are largely silent, and as a result the organization goes around them when it comes time to make key decisions. Sometimes these Managers complain in the background (inappropriately to staff or physicians), or suffer stoically; however, this strategy is not sustainable over the long term, and inevitably leads to built-up resentments and an eventual, often sudden outburst (or resignation). Others do express themselves, but in unproductive ways. There is a right and a wrong way to communicate as a leader; few Nurse Managers have been given the opportunity to learn how to influence people up, down, and across their organization. For instance, how many Nurse Managers know how to construct a business case for an investment or change in patient care model on the unit?

More observations to follow….

Written by Andrew Neitlich.

Developing “bench strength” with a Nurse Leadership Academy

March 20, 2007

Many of our clients come to us because they want to develop their in-house nursing leadership. They have tried without success to recruit strong Nurse Managers and Nursing Leaders, and have determined that it is more cost effective and better for the long-term success of the organization to develop leaders from within.

One way to develop in-house leadership is with a Nurse Leadership Academy.

The program includes the following elements:

1. Selection of high-potential candidates. Many hospitals start with the existing Nurse Managers to create a common language and way of thinking about leadership. Then they involve a second group of high-potential Assistant Nurse Managers and Staff Nurses.

2. Initial welcome, orientation, and content delivery. A two or three day retreat grounds participants in the key elements of being a successful leader in the hospital. At the same time, participants choose ambitious goals to improve quality, service, and cost at the organization. Note that time must be reserved to prepare for this retreat. For instance, we will assess an organization in order to tailor our existing Nurse Manager’s Performance Leadership Program to the specific needs of the organization. Also, we will work with leadership to determine key areas for improvement.

3. Monthly follow up meetings to discuss progress on goals, hear presentations from hospital leadership (e.g., a board member might discuss the role of the board), and learn additional content.

4. Ongoing one-on-one coaching as needed.

5. A formal graduation after a year.

Once a hospital institutes this kind of program, it can expand it to other leaders in the organization, and also begin developing an internal cadre of coaches and mentors.

For a relatively small investment, a Nurse Leadership Academy can make a huge difference in recruiting, retaining, and developing staff — and in improving results and morale.

Are you on top of everything going on in your unit?

January 6, 2007

Suppose your manager (or her manager) came onto your unit right now. Could you answer these questions:

1. Are there any patient safety issues on the unit?

2. Where are we vs. budget this week?

3. How are supplies? Are we within budget? Are any supplies at risk of being expired? Are par levels appropriate? Are supplies organized and accounted for?

4. Have you completed performance evaluations for all of your staff on the unit?

5. What is happening during the afternoon and night shifts?

6. Which patients are ready for discharge, and which are having issues that will lead to a longer-than-anticipated stay?

7. What beds will be available today, and approximately at what time?

8. Is every nurse on the unit safe, competent, loyal, committed, and proud of the results on the unit?

9. How have you interacted with the medical staff today? Are there any issues, complaints, or suggestions from the medical staff we should be considering?

10. Are there any issues with staff that could lead to grievances or that are causing a competent nurse to be a “flight risk”?

These are only some of the details that the effective nurse manager attends to every shift, every day — while also thinking about longer term issues of improving performance on the unit. The best nurse managers are proactive in anticipating problems and resolving them, ideally in a way that inspires confidence from her own manager and frees her manager to focus on other pressing issues.

The nurse manager’s role is a challenging and crucial one, especially because of the myriad issues and details that she must track and handle. This is a position that requires 100% accountability and responsibility, even for things not always within one’s control.

How to know if you have set a productive tone and established high standards on your unit

January 6, 2007

We always know a manager has set a productive tone on her nursing unit and established high standards, when she can assure her manager that on her unit patient care is being given by nurses who are:

1. Competent.

2. Compassioinate.

3. Proud of the outcomes of the nursing unit.

4. Committed to excellence.

5. Committed to the organization’s success.

6. Safe practitioners.

7. Loyal.

Can you assure your manager that the seven criteria above are true for your unit?

Six requirements for building an effective nursing staff team.

January 6, 2007

Over time, one thing remains constant on hospital nursing units: Nurse Managers who build effective teams succeed.

Given the particular conditions facing the healthcare industry today, the challenge of building a high-performing nursing team can seem monumental. You have to deal with the nursing shortage, an aging workforce looking toward retirement, increasingly aggressive union activity, major shortfalls in reimbursement, unavoidable reliance on agency and per-diem personnel, constant introduction of new technologies, and orientation challenges when compelled to hire inexperienced nurses to staff the ICUs and ED.

In this context, the nurse manager may already feel that she is being asked to lower her standards, or to compromise her values. Success in building an effective team requires creativity, focus, and strategic thinking to address these challenges.

There are two non-negotiables: you must maintain quality standards, and you must stay within your budget parameters.

Having laid out the challenges, following are six requirements for building an effective team (and our Nurse Managemer Performance Leadership System goes into depth on each):

1.  Set high standards for yourself and others. Expect a consistently professional, performance-driven tone on your unit.

2. Adapt your management style to specific situations and unit or patient needs.

3. Create a supportive ambiance on the nursing unit. Recognize and reward loyalty, creativity, and commitment to the organization.

4. Use both conventional and creative means to recruit high quality clinical staff. Think beyond traditional attitudes.

5. Use continuous improvement methodology to constantly improve your team’s performance.

6. Manage any labor grievance or union challenge expeditiously.

Assess your alliances

January 6, 2007

There is one attribute that sets the successful nurse manager apart from her peers: alliances.

An effective nurse manager takes great pains to build alliances up, down, and across the organization. She has strong working relationships with her staff, with other departments, with the medical staff, and with upper management.

That way, when she faces a challenging situation, needs immediate access to scarce resources, or has to resolve a conflict, the relationships are in place for her to get results.

Take a moment to assess the strength and quality of your alliances within the organization. Will your staff go above and beyond when required to help you meet budgetary constrainsts? Will the medical staff work collaboratively with you to solve a problem on your unit? With managers of other departments respond rapidly to the occasional demanding request? Is your manager an advocate of you and your ongoing development?

If you have answered “yes” to these questions, than you most likely have formed the kinds of alliances required for success in your role.

If you have answered “no” or “not sure” to even one of these questions, then take some time to consider how you can mend or build the relationship(s) in question. For instance, one of the most common complaints about a manager from nursing staff is, “She isn’t fair.” Be sure that you are rigorously fair in how you schedule, plan weekend shifts, approve vacation time, praise, and discipline your staff.

Held back by presentation

January 5, 2007

We know a talented nurse manager. The CNO of her hospital, who is retiring soon, has thought of grooming her to take her place. The nurse manager is smart, good with people, clinically sound, and understands how to balance quality of care with budget and business realities.

There is just one problem: On the surface she does not immediately present herself like a leader.

For instance:

- She dresses — to put it diplomatically — immaturely. Rather than wearing business attire, she has been known to wear more informal clothing (jogging shoes, brightly colored socks, casual outfits).

- She doesn’t take pains to groom herself professionally.

- She carries herself more like a follower than a leader, as in the slumped way she walks or her failure to make eye contact in discussions.

Her manager has given her advice and feedback about improving the way she presents herself, and she has not really taken the advice to heart.

Some readers might argue that this is foolish, that if her substance is good then who cares about her style?

We argue here that a nurse manager up for an executive team role should be the full package. She needs to present herself as a leader. Otherwise, she gives subtle (and not so subtle) signals to the medical staff and hospital employees that perhaps they should not take her so seriously.

Here is somebody who is 95% of the way towards rising to the top level. Why not go the additional 5% of the way and improve the way she presents herself.

To give a counter example, we know somebody from a different system who received similar advice from a mentor. She took the advice to heart, bought a new wardrobe, changed her hair style, and even took some presentation skills classes. The effect has been transformative — both for her own confidence and in how people respond to her.

Please don’t think that we are superficial. Nurse managers have enough issues to worry about in their roles and careers. Still, why not take care of one aspect of your role that you can control 100%?


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