First Line Nurse Manager:
Past, Present, Future
Edna Cadmus PhD, RN, NEA-BC, FAAN
Clinical Professor, Specialty Director, Leadership Tracks
Co-Lead for NJAC
1
• Define the FLNM work, past, present,
future
• Explore the need for FLNM development
and beyond
• Create the business case for change
• Spark some new ideas!
Objectives
2
PAST TO PRESENT
Healthcare Context
3
Hospital
Based
Community
Nursing
Centralized
Decentralized/
global structures
Nursing
Care
Interprofessional
Teams
Bedside
Care
Population Health
Transactional
leadership
Transformational/
Complexity
Leadership
Changes in Delivery
4
• Managed Care
• Reduce costs/restructure
• Nurse Manager 100 FTEs or
greater
1990’s
Dissatisfied Staff
Dissatisfied Managers
Poor patient outcomes
5
IOM
Reports
Affordable
Care Act
ARRA
Convergence of Forces
Improved Health and
Healthcare System
6
Healthcare Reform
7
• IOM report: “Future of Nursing:
Leading Change Advancing Health”
• IOM report state that “strong leadership is critical if the
vision of a transformed health care system is to realized.”
Further states that the FLNMs are uniquely positioned to
design new models of care to improve quality, efficiency
and safety.”
CONTEXT
8
Is this your desk?
9
Are nurse managers
positioned correctly at the
table? Should others be at
the table ?
10
• Chief Retention Officer
• Engage Employees
• Chief Culture Builder
•
•
•
•
Quality and Safety Officer
Patient Experience Officer
Financial Officer
All other duties as assigned!
FLNM Expectations
11
DEFINITIONS
12
http://youtu.be/UhxINyIZ454
• Leadership
13
• Classical management
• Transaction
• Work for pay
• Work for psychological benefits (status, recognition or
esteem)
• Requires appropriate role behavior
• Requires clear goals and appropriate instructions
• Transactional leadership focuses on the task
Transactional Leadership
14
Transformational Leadership
• Transforms the
environment and the
people in it
• Focuses on building an
appropriate context and on
enhancing the relationships
of people within the
system
Leader
Follower
The environment
15
•
•
•
•
•
•
•
•
Focus shifts to the entire team as change agent
Leadership is a behavior of every individual
Greater engagement by all
Work is facilitated rather than directed-guided by license,
competence and goals
About relationships
Individuals accountable for their work and decisions at point of
care
Teamwork
Individuals self organize around problems to solve
• (Malloch, 2014)
Complexity Leadership
16
• Leadership styles (T& T)
increases nurses’ job satisfaction
• Transactional leadership styles
increase patient satisfaction
• Transformational Leadership style
decreases turnover
• Span of control decrease the
positive effects of leadership
styles(T&T) on nurses’ job
satisfaction
• Wide spans of control decrease
patient satisfaction
• Spans of control increase turnover
•
(Doran et al (2004)
• Transactional leadership alone
did not achieve optimum
outcomes
• Transformational leadership is
needed to increase nurse
satisfaction, recruitment and
retention.
• Significant association
between leadership styles on
patient satisfaction and
reduced adverse events.
•
Wong & Cummings, (2007); Cummings &
Mac Gregor et al (2009).
FLNM Impact on Patient Staff, &
Organizational Outcomes
17
• Vacancy and turnover costs ($82,000-$88,000/RN)
• CMS-24 clinical processes, 8 domains for the patient
experience and outcomes
• weight for 2014 (45%, 30%, 25%)
• Consumer transparency
• Organizational drag
Cost Implications for
Organizations
18
ANTECEDENTS TO TRANSFORMATIONAL
BEHAVIORS AND OUTCOMES
CULTURE
OUTCOMES:
Patient Safety
SKILL SET
FLNM
WORK/ROLE
TRANSFORMATIONAL
LEADERSHIP
BEHAVIORS
Successful
organizational
change
Organizations
competitive
position
19
• Shea-Messler, W. (2007) “Why am I still here you ask? A
phenomenological study of the lived experience of nurse
managers. PhD Dissertation, University of Tennessee,
Knoxville.
• Surakka, T. (2008) The nurse manager’s work in the hospital
environment during the 1990’s and 2000s: Responsibility,
accountability, and expertise in nurse leadership. Journal of
Nursing Management. 16, 525-534.
• Baker, S., Marshburn, D., Crickmore K., et al. (2012). What
do you do? Perceptions of nurse manager responsibilities.
Nursing Management. 43(12) 24-30.
Literature Review FLNM
Work
20
To develop and test a First Line Nurse
Manager(FLNM)Work Instrument that
measures categories of work and
frequency of activities.
PURPOSE OF STUDY
21
• FLNM 24-HOUR 7 DAY RESPONSIBILITY
• UNIT(S)
• INPATIENT OR OUTPATIENT
DEFINITION OF FLNM
22
• NURSE MANAGER SKILLS INVENTORY©
• JOB DESCRIPTIONS (n=11)
• FOCUS GROUPS (2)
• 10 FLNMs
• SURVEY OF CNOS (n=5)
INSTRUMENT
DEVELOPMENT
23
24
FLNM WORK INSTRUMENT
• 87 items and 9 subscales
• Response categories were from never annually
• Subscales
• Financial Management
• Human Resource Management
• Performance Improvement
• Technology
• Strategic/Tactical Management
• Practice
• Personal and Professional
Accountability
• Relationship Activities
• Other
25
• Content Validity
• Focus Groups
• CNOs
• Reliability
• Test/Retest
• % Agreement
VALIDITY AND RELIABILITY
26
•
•
•
•
73 acute care hospitals in NJ (April- Aug 2012)
Solicited via e-mail and letters through CNO
Packet of information was sent to CNOs
Demographics, Survey and Consent via
SurveyMonkey™
• SPSS and SAS used for analysis
DATA COLLECTION &
ANALYSIS
27
DEMOGRAPHICS:
FLNM Characteristics In Percentages
Characteristics
Most Frequent
n=173
Age
20-29
30-39
40-49
50-59
>60
1.2
15.6
32.4
41.0
9.8
Sex
Female
86.1
Highest Level of Education BSN, MSN or PhD
65.4
Ethnic Background
Non-Hispanic/Latino
92.5
Race
White
80.9
28
Range
%
0-2
15
3-5
20.8
6-10
22
11-15
15
16-20
9.2
21-25
6.4
26-30
8.7
>31
2.9
YEARS OF EXPERIENCE AS
FLNMS
29
Category of Work
Item >70% agreement
Financial Management
Making staff assignments
Staffing activities
Determining the operating expenses
Ordering Equipment
Developing a capital budget
Completing payroll
Allocating merit increases
Negotiating prices with vendors
Mentoring others
Conflict management/negotiating with others
Completing performance appraisals
30
Analyzing incident reports
E-mail management
(n=173)
Human Resources Management
Performance Improvement
Technology
RESULTS
Category of Work
Item >70% agreement
Strategic/Tactical Management
Create a business plan for a new program or service
Utilize evidence based practice and research in making
changes
RESULTS CONT.
Plan and prioritize your day
Participate in meetings in organization
Practice
Rounding on unit
Huddles with staff or others
Provide direction to staff on clinical matters
Provides house supervision
Investigate complaints
Work within a shared governance structure
Personal & Professional
Accountability
Going to school to obtain next level degree
Certification maintained in a professional organization
Relationship Activities
Customer service activities
Outreach to internal or external customers
Conducting staff meetings
Other
Copying, Faxing, Answering Phones
31
•
•
•
•
Instability in reliability for some items
Over or under-estimation
Time
Concern for confidentiality
LIMITATIONS
32
• Identify activities that are value added
• Comparisons with others
• Framework for dialogue
• Reallocation of work
Recommendations
33
• What components of the FLNM
could and should be eliminated
for future? (Non-value added)
• What components should be
enhanced? (Value-added)
• How might you cost justify your
proposal?
• How does the FLNM fit into the
new world order?
• What else might you consider?
How might we change the
FLNM role?
34
INVESTMENT FOR THE FUTURE
35
1) Evaluate the work of
the FLNM
• FLNMWI or Nurse
manager/executive
skills inventory
• Create a strategic
direction
Strategies
2) Educate
• Formal education
50% of nurses in
leadership positions in
US have a BSN or higher
(National Sample Survey)
• Partnerships between
academia and practice
36
• Objective- To examine
the relationship of TL
practices, nurse
characteristics and formal
leadership training of
frontline nurse leaders in
a large health system.
• Sample- Surveyed 512 in
23 hospitals using the
LPI.
Results• Formal training
influences only 1
component which is
model the way.
• Formal education had a
significant effect in
improving overall TL
practices and behaviors
that inspire a shared
vision and challenge the
process.
Kelly et al. (2014) The relationship of training and education to
leadership practices in frontline nurse leaders. JONA. 44,(3):
158-163.
37
•
•
•
•
•
•
•
Global mindset
Technology integration
Expert decision-making skills
Quality and Safety as a priority
Political skill
Collaborative and team building skills
Balancing authenticity and organizational performance
expectations
• Ability to cope with change
•
(Huston,2008)
Skills needed
38
• Ability to deal with complex organization behavior:
•
•
•
•
•
•
•
Non-linear
Emergent change
Interaction and interdependency
Unpredictability
Autocatalytic behavior
Dynamic movement
Continuous adaption without losing strategic focus
• Uhl-Bien, M. Marion, R. Complexity Theory for Organizations and
Organization Leadership (2008)
FUTURE FUTURE FUTURE
FUTURE FUTURE FUTURE
Complexity Leadership
39
• Coaching and mentoring
• ONE/NJ Mentoring Program
• Provide resources needed-secretarial support for staffing,
scheduling, payroll, quality and budget monitoring
• ROI
• Unleash their talents
• Be disruptive innovators-Leadership not role defined?
• Engage in decision making around strategic goals
• Position the FLNM and the staff around strategic direction
Solutions Continued
40
41
NURSE MANAGER RESIDENCY
SURVEY RESULTS
Cadmus & Johansen (2012)
42
• Descriptive exploratory survey
• 48 agencies-2011
• Survey participants senior leaders in organizations across
settings
• Questions included:
• Does your organizations have a leadership residency or
comparable program for new FLNMS with less than 2 years
experience?
• If not, would an integrated leadership residency program for
FLNMS with less than 2 years of experience be desirable from the
vantage of a senior nurse leader?
• What possible barriers might appear before sending FLNMS to a
12 month residency program?
Nurse Manager Survey
43
Type of Organization
Number of Facilities
Solicited
n*
% Response Rate
Long Term Care
Facilities
360
24
6.7%
Home Care Agencies
54
4
7.4%
Hospitals
73
18
24.7%
FQHCs
20
3
15%
Total
507
49
Overall:9.5%
Sample
44
Range
% All
settings
% Hospitals
0-25
45.8
5.6
26-50
35.0
38.9
51-75
14.6
22.2
76-100
2.1
5.6
101-125
2.1
5.6
126-150
0
0
127-175
0
0
No response
10.4
22.2
Average number of FTEs in
FLNMS Span of Control
45
Age distribution by %
25-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
>66
5.2
3.7
21.6
9.9
25.8
20.8
8.7
3.7
.6
Highest Education Level
Diploma
Associate Degree
BSN
Bachelors in another
field
Masters in Nursing
Masters in another field
Doctorate of Nursing
Practice
Doctor of Philosophy
16.9
22.9
38.4
5.4
FLNM Characteristics in NJ Across Settings 2011
14.2
1.9
0.2
0.2
39.8%
46
Original Questions
• Does your organizations have
a leadership residency or
comparable program for new
FLNMS with less than 2
years experience?
• If not, would an integrated
leadership residency program
for FLNMS with less than 2
years of experience be
desirable from the vantage of
a senior nurse leader?
• What possible barriers might
appear before sending
FLNMS to a 12 month
residency program?
Responses
• 2/3 did not have such a
program
• 68% responded yes, 17%
no, 15% unsure
• Barriers
• Lack of funding
• 12 months too long away
• Cost/benefit rationale
Cadmus, E. & Johansen, M. (October, 2012). The time is now: Developing
a nurse manager residency program. Nursing Management.
47
• “.. As many areas of nursing are feeling the pinch of
cutbacks, organizations are less enthusiastic to fund
endeavors such as a leadership residency program.”
• Many nurses aren’t well equipped to perform their job
correctly because they lack the educational background.
In fact, I find many nurse managers are practicing
through trial and error, which of course creates havoc.”
Comments
48
• If role is pivotal then we need to redesign it radically
• Leadership needs to go beyond the FLNM
• Structures and processes need to change to produce new
outcomes
• Investment needs to be made for the future leaders
Summary
49
Partial funding of this research was made possible through
• 2011 Dean’s Summer Research Development Program,
Rutgers, CON
• Research Award from the Council on Graduate Education
for the Administration of Nursing(CGEAN)
Acknowledgements of
Funding
50
51
• Cadmus, E. & Wisniewska, E. (2013). Measuring first
line nurse manager work: Instrument: Development and
testing. JONA 43(12): 673-679.
• Cadmus, E. & Johansen, M. (2012). The time is now:
Developing a nurse manager residency program. Nursing
Management. 43(3): 18-24.
Publications for Studies
52
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