Understanding Nursing Leadership

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Who You’ll Hear

Kati Kleber, MSN RN– Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, and speaker.

Melissa Stafford, BSN RN CCRN SCRN – highly experienced and currently practicing nationally certified neurocritical care nurse.

Megan Brunson, MSN RN CNL CCRN-CSC, former President of the  American Association of Critical Care Nurses (AACN)

What You’ll Learn

• Introduction
• Role of a Supervisor
• Chain of Command
• Advice for New Nurses
• Conflict with Physician
• Encourgement
• Night Shift Supervisor

Understanding Nursing Leadership

Ever wonder about how the bedside nurses work with nursing leadership? We interview Megan Brunson, a current practicing nursing supervisor, and discuss how the bedside nurse can leverage leadership in various patient situations.

Please note, in this episode, we talk about the AACN a lot – this stands for the American Association of Critical-Care Nurses.

The Role of A Supervisor

This can be different at different facilities. This is generally what this role means:

• Some hospitals call them assistant managers
• Many facilities have an assistant manager for the day shift and another for the night shift
• Then there  is a manager over the entire unit
• A supervisor or assistant manager helps manage the nurses by:
  • Scheduling
  • Helping with clinical needs
• Primary responsibilities:
  • Offer clinical support by answering questions
  • Offer support to help pull up or reposition a patient
  • Offer support listening to nurses that need someone to talk to about job-related questions and problems
• In the night shift, leadership presence isn’t always there for nurses.
• Works a 12-hour shift
• Paid hourly, not salary
• Having a supervisor that understands both the clinical side and management side is critical to providing excellent support to both the nurses and the upper management.
• The hardest job in health care is a nurse manager.
• Best way to be a nursing supervisor is to remember details about the nurses in your care
  • Create an intimate rapport with them
  • This increases their trust in you as a leader
  • It helps the leader build the team so they know how to use their talents best

Chain of Command

Next we discuss exactly what chain of command means to a new nurse, and how to enact it in the most politically correct way possible.

• There is a reality in hospitals that you have to follow the process of the chain of command.
• Chain of command essentially means that you’re hitting a roadblock with someone and you need to escalate the concern
  • For example, you have a concern about a patient and the resident does not agree. Escalating that would mean speaking directly with the chief resident or the attending.
  • Another example is that you have a conflict with your colleague and attempt to discuss it with them and they are non-responsive, then you go to your supervisor, then your manager, etc.
• Following the chain of command process protects you as a nurse and it protects the managers and administration
• On the night shift, the night shift supervisor or charge nurse is a nurse’s first step
  • Communication is key. Sometimes the person a nurse is having a conflict with doesn’t even know.
  • It is important and part of a nurse’s role to give them a shot and be honest about the things that bother or upset them.
  • If they are not receptive or they lash out, then they are accountable for their behavior and you can go to the next level.
• The direct method for handling conflict is always the best way.
  • It leaves your vulnerable and it is scary.
  • It avoids a triangular situation where you don’t know if the person was told about your conflict or if it was ever resolved.
• Another option is to pull someone in and go together to resolve the conflict.
  • Other experienced nurses have experience with these crucial conversations and can be a huge support system.
• Sometimes a nurse has to go around the chain of command because the direct supervisor is physically not there.
• It is a good idea to pause, write down what bothered you, and think it through before going up to the next supervisor.
  • This helps you sort through your thoughts and put them together professionally.
  • Do not have an emotionally-driven conversation
• When looking for support, be selective with whom you let into your circle of trust
  • Don’t foster drama or encourage gossip
  • It can create a very unhealthy environment within which to work

Advice for New Nurses

Advice from a night shift supervisor to new nurses that might be facing issues with their manager or direct supervisor.

How to navigate issues with direct supervisors or managers:

• AACN has valuable resources such as Healthy Work Environment Standards which covers:
  • Staffing
  • Communication
  • Creating a healthy culture within the unit
  • New nurses should read these standards
• If you have a problem with a new nurse manager or a nursing preceptor, try this:
  • Set the expectation correctly –
    • Take a moment to say to the preceptor, “This is where I am coming from. This is the kind of patient care I’m looking for. This is the experience that I need. I’m concerned because I’m really having trouble with ______.”
  • Set expectations with how you like to learn, too.
    • “I’m a very visual person.”
  • If you set the expectations clearly, there won’t be any surprises when you have a dialog later on.
  • It helps foster trust at the start of your shift.
  • It’s ok to say “we are not clicking.” It doesn’t necessarily offend the preceptor.
  • It does take courage to come forward and ask to change preceptors.

Advice for Nurse who Has Conflict with Physicians about Patient Care

If you have a new nurse that has a concern about a patient, calls the physician and doesn’t receive an appropriate response for the issue, this is what they should do:

• Always go with your gut, but don’t do it in a silo.
• The senior staff knows the physicians really well – walk through the situation with them
• As a new nurse, you have a responsibility to build trust with that physician too.
• Bring in your charge nurse or an experienced nurse.
• Before you call the physician, write down on a piece of paper what you want to say.
• Sometimes with a physician, it isn’t what you said it is how you said it.
• Unless it is something like a completely inappropriate medication, do what the doctor says, but then call them right back.
• There is a chain of command with physicians.
  • It doesn’t happen very often where you have to go to that physician’s chain of command.
  • In that instance, you would pull in the overall house supervisor.
• Be assertive and clearly communicate details when you discuss patient care with physicians.
• If you need to call back, as the charge nurse to listen on the other line.
  • It wakes up the situation
  • Charge nurse can help clear up miscommunications

Encouragement for Nurses With Barriers to Leadership Support

Helpful tips for new nurses that have actual or perceived barriers to leadership support.

• As a nurse, recognize that you are a leader.
  • Even as a day-1 nurse, you are a leader in that unit because you are setting the tone for that unit.
• When you say you have perceived barriers with leadership some of it might just be not knowing that person.
  • You might not have any personal connection to them.
  • You might not know their clinical background experience
• Don’t be so task-oriented that you overlook getting to know your team.
• Come in 10 minutes early and stay 10 minutes late. When you are getting your assignment, have a discussion with the buddy you will be working with all night, such as:
  • Learn basic personal details (“what did you do this weekend?”)
  • Build rapport
• When you are in critical situations with patients, you have the rapport and established relationship that will help you navigate it easier.
  • It makes escalated conversations more comfortable.

Night Shift Supervisor Soapbox

A few last words from Megan Brunson to brand new nurses.

• For night shift nurses – don’t mess around with your sleep.
  • Map it out
  • When new nurses come to the night shift, they don’t take into account their sleep and they make appointments during the day when they should be sleeping.
  • How much sleep you get affects the health of the patients and your entire mindset at work.
• From a leadership perspective, build trust with the people around you.
  • This includes the day shift too.
  • They will have your back as well as you have theirs.
• Get to know the leadership in your unit.
  • Whether that is the charge nurse or the experienced nurse
  • Find out who has the listening ear. You will get frustrated. These are normal feelings and you need someone with whom you can talk about it.
• Never use the night shift as an excuse to not get involved.
  • I ask people to speak up for the shift
  • A meeting in the afternoon won’t work, but I want to be involved in that committee, can we meet at 4:30 p.m. or 7 a.m.?
  • Your professional development ultimately feeds back into the patient care you are giving.

More Resources

• The Unspoken Nursing Hierarchy and Why It’s Garbage
• How to Become a CNS: 6 Realistic Steps
• The Role of the Nurse Preceptor: A Three-Part Series
• Tips for New Nurse Preceptors