Wednesday, March 22, 2006

Management

I think there is problem with the way nursing management is structured in the U.S. The problem is that nurse managers do not actually work in the units they manage, so they often don’t experience first hand the problems they need to help solve. For example, in our hospital, and in almost all U.S. hospitals, the chief of neonatology takes his turn working in the NICU just like the other neonatologists, rounding and taking night calls. The same is true for the chiefs of other clinical departments. But the nurse manager of our NICU never does a shift alongside the NICU nurses. She never does the same work the other nurses do. Instead, she spends most of her time in the office dealing with scheduling, policy, and other matters.

As a result, I and the other neonatologists know more about her nursing staff than she does. We know which nurses are good and which are not. We have to inform her when they are doing a good job or making mistakes. I’m not sure why nursing management has evolved this way, while physician management has kept the chief doing the same work as the others, but it should change. I think every nurse manager should do at least one shift every week or two simply doing the regular work of a unit.

Don’t get me wrong. Our nurse manager is an excellent person, but the structure of her job is flawed. Also, this is not a diatribe against nursing. Most of our nurses are good, and working with a good nurse is very gratifying, knowing you can trust them to do what is best for the patient, and knowing they’ll probably catch something if you miss it. But this is one instance where I think the medical model is better.

10 Comments:

Blogger Dream Mom said...

I have spent a lot of time in hospitals with my son-42 different hospitalizations over 14 years (this does not count the ER visits) so I too am keenly aware of which nurses are the good ones.

Unfortunately, in the hospital that we use the most, they have one nursing problem that drives me crazy. Most of the nurses do not know how to use a feeding tube. Dear son uses it just for meds and it's great if I have a night nurse that knows how to use one. Dear son gets his last seizure med at midnight (he's on 7 plus has a VNS) and it's a real treat if they know how to do it because it means that I can go to bed before midnight and get a few extra winks!

This is a children's hospital that is one of the top 100 hospitals in the country yet most pediatric nurses don't know how to use it for meds. I have seen them crush up pills and try to put "dry" pills through the tube. I've had several try to "pour" the meds in which takes forever (it's much faster with a syringe). I had one break the balloon of the feeding tube because she put it in the wrong end. I had to drive home to get my spare one (they cost $300 per tube!) because the ER didn't carry the mini buttons and the clinic didn't open until 8 a.m. and he had meds at midnight and 6 a.m. so I couldn't wait. What I can not understand for the life of me is how so many of these nurses do not know how to do this and yet the majority of the children that are hospitalized there are "special needs".

I also had a surgical nurse who fitted my son with the wrong size feeding tube (she assisted with the surgery to put in the tube and she did all follow up visits) which blocked his stomach opening and he vomited for months and endured many hospitalizations before they could figure this one out! The last hospitalization was 32 days and cost over $200k with $150k due to the error (he had a $50k surgery to implant the VNS at that time).

This hospital recently hired a lot of new "younger" nurses (according the the nurse on staff). Hopefully, someone will train them.

Maybe your solution would help. I have reported this problem before but it still existed over a year later and they said they were "working" on it.

9:36 PM  
Blogger Judy said...

Neonatal Doc,
I guess my hospital isn't the only one with that particular model. Back in the dark ages, we had a nurse manager (called head nurse at the time) who could put on scrubs and take an assignment when needed. So could our director of maternal-child health.

No more. The current nurse manager probably doesn't know what half of the staff looks like. The docs all do. They show us a lot more respect, too.

10:06 PM  
Blogger Flea said...

I'm not sure what you're getting at here, ND. You seemed to be on to something but it feels like you didn't flesh it out. I'm not criticising your excellent writing, it's just that, well, I don't get it.

You know the nurses better than the nurse manager. So? What's her job anyway? To know the nurses better than you? Something else?

best,

Flea

5:45 AM  
Blogger neonataldoc said...

Dream Mom, I'm sorry about your experiences. But I've known so many excellent nurses with a lot to offer that I hope you and your son experience those too.

Judy, yes, I sometimes wish for an old fashioned head nurse.

Flea, I guess it just seems like there is no clinical leadership in nursing. There is no leader who can show them how to do things when they don't know how. There is no one in authority in the unit to enforce policy. And when problems need to be solved, it would help if they knew the ins and outs of the unit to help solve them.

P.S. If I write a new post every two days, do they all have to have a point? :)

10:43 PM  
Anonymous Anonymous said...

I've been a nurse for 20 years now. I think you are really onto something!
We used to have clinical nurse specialists/educators, whose job was to be the expert on bedside care and the knowledge required. Maybe my current hospital is too small for this person, they laid off the last educator for financial reasons. What I do know is that the current model for nursing management is not working!! It is exactly as you say, our manager doesn't know her staff, who's good and who isn't. It is very frustrating to work in this environment.

11:58 AM  
Blogger anna said...

NICU nurse here.....cant agree with this post more!!!!! in fact I was really struggling one day when we were very busy and all 3 charge nurses were busy helping with admissions the transport nurses wer out on transports, etc.....basically i called a manager for help, 2 managers came and did care for one of my kids (vitals, diaper change, feed...easy stuff) it took 2 of them an HOUR to do what probably should take 15 minutes. i laughed at them at the time....but thinking about it it sure would be nice if they were still involved enough in pt care to where they could step in and help efficiently when needed

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