Journal of Gerontological Nursing

Feature Article Supplemental Data

Through the Eyes of Nurse Managers in Long-Term Care: Identifying Perceived Competencies and Skills

Kathleen H. Dever, EdD, MS, RN

Abstract

Nurse managers (NMs) in long-term care supervise health care services for individuals with high acuity levels and numerous comorbidities. There is minimal research identifying NMs' skills and competencies as unit leaders within the long-term care environment. The current mixed-methods study identified NMs' leadership skills and competencies. Nineteen NMs with ≥5 years' long-term care management experience completed the Nurse Manager Inventory Tool and were individually interviewed. They rated their clinical skills at the competent level and their financial/strategic management skills at the novice level. All other skill categories, including leadership reflective practice, diversity, human resource leadership/management, relationship management, performance improvement, and problem solving, were rated at a competent level. Emergent interview qualitative themes included their visibility on the unit, trial and error learning, a sense of “aloneness” due to the absence of other RNs, NM position being a tough job, need for peer support, role modeling, and importance of supporting the resident through their “final journey.” [Journal of Gerontological Nursing, 44(5), 32–38.]

Abstract

Nurse managers (NMs) in long-term care supervise health care services for individuals with high acuity levels and numerous comorbidities. There is minimal research identifying NMs' skills and competencies as unit leaders within the long-term care environment. The current mixed-methods study identified NMs' leadership skills and competencies. Nineteen NMs with ≥5 years' long-term care management experience completed the Nurse Manager Inventory Tool and were individually interviewed. They rated their clinical skills at the competent level and their financial/strategic management skills at the novice level. All other skill categories, including leadership reflective practice, diversity, human resource leadership/management, relationship management, performance improvement, and problem solving, were rated at a competent level. Emergent interview qualitative themes included their visibility on the unit, trial and error learning, a sense of “aloneness” due to the absence of other RNs, NM position being a tough job, need for peer support, role modeling, and importance of supporting the resident through their “final journey.” [Journal of Gerontological Nursing, 44(5), 32–38.]

The population of the United States is aging at a rate faster than previously experienced, with projections that 88.5 million individuals will be ≥65 years old and 19 million individuals will be ≥85 years old in 2050 (Vincent & Velkoff, 2010). Approximately 1.2 million individuals live in long-term care facilities in the United States, and in 2014, approximately 15,634 long-term care facilities existed in the United States (Centers for Medicare & Medicaid Services, 2015). Nurse managers (NMs) in long-term care are usually RNs responsible “for assuring the quality of clinical care in long-term care settings, assessing health conditions, developing treatment plans, and supervising Licensed Practical Nurses (LPNs) and paraprofessional staff” (Harahan, Stone, & Shah, 2009, p. 5). Due to an insufficient number of RNs in long-term care, the NM may be the only RN on the unit, and it is common to advance an RN without management experience or leadership training to the NM position. The purpose of the current research study was to explore NMs' perceptions of their management competencies to direct the resident and staff activities on a long-term care unit.

Previous research studies have suggested ≥10 years of dedicated, continuous service in a particular field to define expertise (Ericsson & Charness, 1994). Expertise in a specific clinical area of nursing has been defined as ≥5 years of continuous service (Benner, 2001; Benner, Tanner, & Chesla, 1992, 1996). Research to support leadership outcomes, including resident quality of care and staff retention, is available for acute care settings, but little research identifies NMs' leadership effectiveness in long-term care (Bourbonniere & Strumpf, 2008; Harvath et al., 2008; McGillis Hall et al., 2005; Wilson, 2005). Previous long-term care research has focused on traits and behaviors of the Director of Nursing (DON) as the organizational nurse leader (Anderson, Corazzini, & McDaniel, 2004; Anderson, Issel, & McDaniel, 2003; Hunt et al., 2012), yet few studies have been performed for traits and behaviors of NMs as unit leaders. NMs, as unit managers, oversee the patient care planning process, clinical care, staff management, unit organizational support, cost effectiveness, and quality outcome (Anderson et al., 2003; Bedin, Droz-Mendelzqeig, & Chappuis, 2013; Dellefield, 2008; Dellefield, Castle, McGilton, & Spilsbury, 2015). In addition, 75% of RNs in long-term care have an associate or diploma degree as their highest educational level. This level of education focuses on preparing the RN for a role as a clinical nurse and may not adequately prepare the RN for a leadership role. Harvath et al. (2008) defined the effectiveness of nursing leadership in long-term care and hypothesized that the organization's support of leadership training and mentoring would improve the quality of care and “stabilize the workforce” (p. 195).

Research Design

As little research supports NM leadership in long-term care, a qualitative phenomenological approach was used. It is critical in a phenomenological study that the researcher be focused on the participant's vision of the essence of the phenomenological experience (Creswell, 2007). Multiple forms of data collection are used so the researcher can learn “the meaning that the participants hold about the problem or issue” (Creswell, 2009, p. 175).

Method

The current research study used an exploratory descriptive qualitative design to identify the skills, competencies, and expertise of NMs as leaders who work in long-term care organizations. Prior to the start of the research study, permission from the Institutional Review Board was obtained to ensure participant confidentiality and informed consent. Permission was also obtained from each long-term care organization through its individual review processes. The DON in each organization agreed to participate and identified NMs with >5 years' NM experience. All participants signed a consent form for participation. The phenomenon of study included the components of skills acquisition, development of leadership competencies, and the embedded knowledge of the NM along a continuum of novice-to-expert experiences (Benner, 1996, 2001). The study used several methods to triangulate the data, including a demographic survey, the Nurse Manager Inventory Tool (NMIT; American Organization of Nurse Executives [AONE], 2018), and semi-structured interviews (Dever, 2010). According to Creswell (2007), triangulation of data is achieved through various “sources, methods, and investigators to establish credibility” (p. 204) to support trustworthiness of the research.

In 2006, the AONE and American Association of Critical-Care Nurses created a leadership partnership, developing the NMIT survey using a Likert scale from novice to expert for NM self-assessment and supervisory evaluation. The AONE Chief Executive Officer gave e-mail permission to use the NMIT tool for the current research (P.A. Thompson, personal communication, July 20, 2009) and indicated that validation of the tool's competence was achieved through a previous analysis of the AONE NM certification examination that correlated to the inventory tool.

In addition to providing demographic information, NMs independently completed the NMIT as a leadership skills self-assessment based on Benner's definitions for the novice-to-expert rating scale (Benner, 2001; Benner, Tanner, & Chesla, 1992). The respective DON also independently completed the NMIT as a supervisory evaluation. The following leadership and management skills are included in the NMIT survey: (a) clinical, (b) leadership reflective practice, (c) diversity, (d) human resource leadership, (e) relationship management, (f) performance improvement, (g) problem solving, (h) human resource management, (i) strategic management, and (j) financial management. Surveys were returned to the researcher for analysis. Following survey analysis, NMs were scheduled for one-on-one interviews with the researcher to further identify NM leadership and management skills, roles, and responsibilities. Interview questions were based on the NMIT leadership survey analysis. NMs were presented a copy of the summary descriptions for the novice, competent, and expert levels at the beginning of the interview (Table A, available in the online version of this article) and NMIT category headings were used as interview questions. The researcher repeatedly reviewed ATLAS.Ti®-downloaded transcripts to develop codes until a 90% intercoder agreement was reached. Data review was based on the NMIT interview categories.

Nurse Manager Inventory Tool (NMIT): Novice, Competent, and Expert Definitions

Table A:

Nurse Manager Inventory Tool (NMIT): Novice, Competent, and Expert Definitions

Setting

The setting for the current study was a city in Western New York State with an approximate population of 200,000 (U.S. Census Bureau, 2010). Five long-term care organizations located in the city agreed to participate in the research study. Each organization is non-profit, separately owned and operated, and includes continuums of care. These organizations have high standards of quality, are considered premier long-term care facilities, and have strong community ties. The New York State Department of Health provides regulatory oversight for these long-term care settings. The number of long-term care beds ranged from 183 to 591. Nurse administration in each facility includes a DON and Assistant Director of Nursing (ADON). NMs are supervisors of individual units, with the number of patients per unit varied based on the organization size.

Participants

A purposive sample was used for the study and DONs identified NMs. The criteria for inclusion in the study were: (a) ≥5 years of NM experience, (b) experience as a NM at current or previous positions, (c) ability to complete self-evaluation within 1 month, and (d) ability to be individually interviewed within 2 months.

Forty-five NMs worked in the five long-term care organizations, with 28 meeting the criteria for inclusion. Nineteen NMs with ≥5 years' NM experience agreed to participate in the survey and open-ended interview. The Table summarizes NMs' educational levels, RNs' years of service, and NMs' years of experience.

Nurse Manager (NM) Characteristics (N = 19)

Table:

Nurse Manager (NM) Characteristics (N = 19)

NMIT Survey

The independent-samples t test compared mean scores of NMs in the NMIT categories to mean scores of the DON responses in the same categories (Table B, available in the online version of this article). Based on the NM and supervisor t test results, there was no evidence that the two populations differed in mean levels. Interview questions were developed from analysis of the NM and DON responses on the NMIT.

NMIT T-test results NM and DONNMIT T-test results NM and DONNMIT T-test results NM and DON

Table B:

NMIT T-test results NM and DON

Interview Results

Interview questions were open-ended for NMs' skills, competencies, and expertise in their management role (Table C, available in the online version of this article) and the following categories.

Nurse Manager Interview Questions

Table C:

Nurse Manager Interview Questions

Clinical Skills

Despite years of nursing experience, only three NMs rated themselves as expert clinicians, 12 rated themselves as competent, and four rated themselves as novices. One NM indicated that technological and clinical advancements required learning new clinical and managerial tasks every day, thus supporting a sense of always being at a novice level. When interviewed, NMs responded that clinical expertise was necessary due to increased resident acuity levels and lack of unit RNs. The NMs described a “do it all” approach for unit clinical management and a sense of “aloneness” for clinical decision making. Twelve NMs responded that they were the only RN on the unit and six indicated one other RN was present. Due to increased clinical needs, NMs used intuition/gut feeling and/or trial and error decision making. Peer support and a constant state of learning were critical (Table D, available in the online version of this article).

NM Interview Themes and Supportive Quotations.NM Interview Themes and Supportive Quotations.NM Interview Themes and Supportive Quotations.NM Interview Themes and Supportive Quotations.NM Interview Themes and Supportive Quotations.NM Interview Themes and Supportive Quotations.NM Interview Themes and Supportive Quotations.NM Interview Themes and Supportive Quotations.NM Interview Themes and Supportive Quotations.NM Interview Themes and Supportive Quotations.

Table D:

NM Interview Themes and Supportive Quotations.

Leadership Reflective Practice

For the interview, leadership reflective practice was defined as the constant state of learning and self-improvement. NMs identified the importance of constantly improving their leadership practice and remaining open to new learning opportunities. Five NMs scored holding the truth (integrity) at expert level and four NMs scored discovery of potential at expert level. Other NMs scored the integrity, discovery of potential, and leadership reflective practice at the competent level. Several themes were identified during the interviews, including need for constant learning, trial and error, NM position being a tough job, and need for additional training (Table D).

Diversity

In the interviews, diversity was defined as the ability to work fairly with staff or residents in regard to differences in race, gender, religion, sexual orientation, and generation. Overall, NMs responded at the competent level for diversity. Three NMs individually rated themselves at an expert level for social justice; two rated themselves as experts for cultural competence and generational diversity. NMs clearly stated that everyone had a right to be respected and it was imperative to keep an open mind and not be judgmental. Most importantly, the focus of care was the resident and the fact that each individual had worth. During the interview, NMs identified several themes: knowledge of diversity is a job expectation, resident care is a priority, staff diversity is constant, communication is critical, open door policy should be used for employees, personal values should be known, and increased training is needed (Table D).

Human Resources Leadership

The human resources leadership category included performance management, staff development, coaching, and mentoring. One NM rated at an expert level for three of the sub-categories and other NMs rated at the competent level. When interviewed, NMs responded that it was a daily expectation to coach and mentor staff. Most NMs were comfortable with the coaching and mentoring process, learning from experience, trial and error, and supervisory or administrative support. Identified qualitative themes included visibility on the unit being critical, importance of coaching and role modeling for staff, and need for peer support (Table D).

Relationship Management

In regard to the relationship management category, NM responses were equivalent to the competent level. Two NMs scored at an expert level for communication, emotional IQ, self-awareness, team dynamics, and collaborative practice. In regard to the interviews, the focus was communication skills and conflict management. All NMs agreed that communication was an essential skill, required an open dialogue, and was a job requirement to maintain relationships among residents, staff, and family members. Most NMs were not comfortable with resolving conflict. Several themes emerged from the interviews, including importance of relationship development, need for visibility on unit, job expectations, importance of listening skills, trial and error problem solving, and need for peer support (Table D).

Performance Improvement

Performance improvement included knowledge of tools for quality improvement and patient and work-place safety. NMs identified that performance improvement was an organizational expectation accomplished through visibility on the unit. For this category, NMs rated themselves as competent. Only one NM rated as an expert for patient safety and interdepartmental communication. Although NMs were confident in their skills for resident and workplace safety, they were less comfortable with the quality improvement measurements. NMs defined similar themes for this category, including job expectation, importance of visibility on unit, need for peer support, trial and error approach, and importance of coaching (Table D).

Problem Solving and Decision Making

Problem solving results were at the competent level. One NM scored decision making at an expert level. NMs identified that a role expectation was being the “point person” for unit resident, family, or staff problem solving, and the “buck stops here” approach. They learned problem solving techniques through experience. Making decisions was an expectation, but there was a sense of aloneness when doing so. NMs learned through trial and error and gathering experience while maintaining a balancing act between all job responsibilities. Along with resident and staff problem solving, the NM was also responsible for addressing family issues.

Human Resources Management

The human resource management category included questions about recruitment, interviewing, the hiring process, and staff orientations. In this category, NMs scored at the competent level. NMs stated that recently, they were involved in the interview process. According to most NMs, the ability to interview and choose their own staff was beneficial to quality resident care and staff team building. Many NMs did not receive formalized interview training but were supported through Human Resources, supervisory, or peer instruction. During the interviews, themes were identified: increased involvement is needed, competence is critical, intuition is supportive, and experience is necessary (Table D).

Strategic Management

NM responses for strategic management were at a novice level. One NM individually scored at an expert level for presentation and persuasion skills, and another scored expert at project management. Strategic management included identification of the facility strategic plan and unit NM responsibilities. NMs were generally aware of their organization's strategic plan but were somewhat uncertain what their role was in that plan. The strategic planning themes included strategy completed by others and support for the importance of acute care strategic experience.

Financial Management

The NMIT financial management overall category score was at a novice level and included unit budget creation, analysis, evaluation, and monitoring. Several NMs rated themselves at a competent experience skill level. Overall, NMs were not comfortable working with budget creation, analysis, and evaluation due to lack of experience and education, They were more comfortable with their involvement in the unit expenses and variance reports, as this was a job requirement and they intuitively knew on a day-to-day basis what supplies and equipment were used.

Final Journey

Throughout the interviews, NMs identified the provision of resident/family support at the end of life as a critical NM role, as most long-term care residents live their final days in these facilities. Several NMs identified the final journey as a positive journey in which they were deeply and willingly involved. Interestingly, NMs accepted their roles as participating and coordinating the final journey and considered it an honor to be part of this journey with residents and their families. As one NM stated, “It's not just everybody is here to die. Everybody is here to live and experience complications along the way that we must try to figure out how to deal with, but it's a different way of thinking.” Another NM explained that, “long-term care to me, that's their home… their quality of life. That to me is you want to make their last few years the best that they can be.” And, according to another NM, “it's the end of the life; you're going to journey through the final stages where you might not do that in the other settings. So you connect with families in ways that you wouldn't necessarily in other settings.” NMs' involvement with comfort care, teaching, and clinical assessments, as well as simply being present, supported resident outcomes that did not prolong but supported the quality of the resident's life through his/her final days.

Discussion

As the nurse progresses through the expertise levels from novice to expert, there is a transition from follow-the-rules detachment to an experienced, emotional attachment, generally occurring after 5 years of focused clinical experience (Benner, 1996, 2001; Benner et al., 1992). Benner et al. (1992) also identified embedded knowledge as an intuitive “knowing how,” and stated that expert nurses could “describe clinical situations where his or her interventions made a difference” (p. 406). Little novice-to-expert research is completed in long-term care, and no research was identified for NM leadership development in this setting. In the current study, all NMs had ≥5 years' NM experience, yet few NMs responded at an expert level in the survey. NMs stated that their clinical skills should be at an expert level due to caring for residents at higher acuity levels; however, their scores did not consistently reflect that belief. In the interview, NMs identified a clinical intuition (gut feeling) that can be equated to embedded knowledge, but NMs did not equate the intuition with expertise.

According to Wilson (2005), in rural acute and long-term care, nurses who were considered excellent from a clinical perspective were often placed in a leadership role without the benefit of management education. Most NMs in the current study stated that they began their career in long-term care as clinical coordinators with specific clinical job responsibilities and were asked to be the unit NM because they were excellent in their clinical role, but they did not have the benefit of management training. Many NMs indicated that they learned through experience, which included daily trial and error and peer support. NMs usually sought the support of nursing administration for more difficult problems or issues.

Dellefield et al. (2015) identified that RNs positively impact residents' experiences based on their leadership abilities, thus supporting the need for formalized NM leadership training in long-term care. Wilson (2005) stated that in long-term care, increased stress levels “coupled with a lack of knowledge and skills in management competencies such as human resources or budget management can be devastating for the new manager and the organization” (p. 138). NMs in the current study considered their financial and strategic management skills to be at a novice level and human resource responses were at the competent level. Many NMs learned how to effectively manage through trial and error and peer support.

Further, NMs stated in interviews that they were stressed and extremely busy on a daily basis due to the scope of their supervisory responsibilities. Identified long-term care supportive supervisory skills and responsibilities include considerate listening, awareness of staff personal issues, provision of positive reinforcement, respect and trust, and role modeling (Dellefield, 2008; McGillis Hall et al., 2005). NMs identified behaviors as critical for staff support: visibility on the unit, listening and an open door policy, coaching, and role modeling. Jennings, Scalzi, Rodgers, and Keane (2007) defined competencies of leadership and management in acute care settings as: management and business skills, communication, health care knowledge, setting the vision, developing staff, and independent thinking. These competencies are also critical for long-term care. NMs were competent in their clinical skills but identified their business skills at a novice level. Furthermore, their communication, relationship, human resource, and leadership reflective practices were at a competent level. In most facilities, NMs did not have the opportunity to be visionary and lacked educational support in these areas.

An expert panel conference conducted by the John A. Hartford Institute for Geriatric Nursing further stated that “increases in the education level and training of nursing staff are also strongly recommended as a step to improving quality of care and reducing turnover rates in nursing homes” (Harrington et al., 2000, p. 14). The impact of a baccalaureate level education is critical considering increased resident acuity care levels, NM turnover, empowerment in the role, and resident quality outcomes (Backhaus, Verbeek, van Rossum, Capezuti, & Hamers, 2015; Hunt et al., 2012). Bedin et al. (2013) stated, “The registered nurse in a nursing home is similar to an orchestra conductor. That comparison calls upon several types of competencies: management, clinical, educational, and ethical” (p. 118). Clearly, NMs' competencies must be developed over time through educational support and guided mentorship.

Future of Leadership Development in Long-Term Care

NMs will play a key role in the future of long-term care, especially with increased resident acuity levels and resident aging. For this reason, participants were asked their opinion of leadership development. All participants agreed that NMs' clinical skills would continue to be important for resident outcomes. As one participant expressed, “The NM in particular in long-term care has to be at the top of the game. They have to be strong clinically; they have to be strong with their leadership abilities and critical thinking.” NMs expressed a sense of optimism about their role for resident outcomes through person-centered care strategies and staff coaching. Interviewees clearly stated that the increase in resident acuity levels would require additional nursing support. One NM stated:

I think if we continue to have the support, continue to have the education, continue to…have the confidence of the people, that we can do our job and continue to do it in the future and be there as a leader.

Implications

Because many NMs were concerned about being the only RN in their respective units, it would be advantageous for long-term care organizations to identify, at a minimum, a RN and clinical care coordinator (also a RN) on each unit to provide the clinical support needed, enabling NMs to focus on teaching and coaching, developing relationships and trust, and advocating for residents and staff. According to Bourbonniere and Strumpf (2008), 75% of RNs in long-term care settings have an associate or diploma degree. In the current research, 63% of NMs who participated had either an associate or diploma degree. The impact of a baccalaureate degree in nursing would support leadership, increased acuity, and levels of care needs. In addition, organizational tuition reimbursement programs can provide support for NMs to advance their degrees to the BSN and MSN levels.

It is suggested that administrators consider development of nursing shared governance programs through involvement of the DON, ADON, and NMs. According to McDowell et al. (2010), shared governance is an “organizational framework that affords nurse professional autonomy, empowers professional nursing staff and managers to contribute to the decision-making process” (p. 33). Nurses should be involved in consensus decision making at all levels of the organization, providing clinical and leadership input.

Long-term care organizations should consider NM leadership training and mentorship programs specific to NM needs that encompass the NMIT skills and competencies. Educational leadership opportunities, including continuing education and conference offerings, support the importance of individualized leadership training. To reduce NMs' sense of aloneness, NMs can develop peer networks that meet on a regular basis to share management and leadership best practices.

Conclusion

The current study focused on the nurse leadership and management skills, competencies, expertise, and embedded knowledge of NMs in five long-term care facilities located in Western New York. Using Benner's clinical novice-to-expert framework in a leadership setting, nurses should move through five levels of leadership expertise development, from novice to expert, over a defined time-frame. Within the five organizations, 19 NMs who had ≥5 years' leadership experience completed the NMIT leadership survey on a novice-to-competent-to-expert scale and were interviewed with questions based on survey responses. Survey results indicated that even with >5 years' leadership experience, NMs collectively did not identify themselves as experts in these categories. Only three NMs indicated expert level for clinical skills. The NMs indicated competent level in most categories. All 19 NMs were interviewed after survey completion and several themes were identified, including aloneness, intuition/gut feeling, increased acuity levels, trial and error leadership, need for peer support, training needs, resident priority, and NM position being a tough job.

Minimal nursing research was identified to support the novice-to-expert clinical model in long-term care organizations. In addition, no research was available to support novice-to-expert long-term care nurse leadership development. Most NMs did not receive formal training or education for their leadership role and were chosen based on clinical expertise. Leadership knowledge was acquired primarily through trial and error or peer support, as formal training was not provided. With identified leadership and management education, mentoring and strategic management support, and a focus on NM development on the novice-to-expert continuum, the NM role in long-term care can be instrumental for resident quality of care, staff retention, and organizational success in the future.

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Nurse Manager (NM) Characteristics (N = 19)

Variablen
Certification
  CNA5
  LPN3
  CNA/LPN4
Degree
  Diploma4
  AAS14
  BSN7
  BA/BS/MS5
Years as RN
  0 to 102
  11 to 204
  21 to 305
  31 to 408
Years as NM/Supervisor
  0 to 105
  11 to 2011
  21 to 302
  31 to 401

Nurse Manager Inventory Tool (NMIT): Novice, Competent, and Expert Definitions

Novice: At this level, the nurse manager is learning basic management skills. The novice is rules oriented and somewhat inflexible. The novice is guided by the organization policies and procedures. The lack of experience and competence leads to ineffective decision making. The novice nurse manager needs a mentor to provide guidance and begins to establish a trust in peer relationships. The novice needs help to differentiate the importance of tasks and is not able to multi-task effectively.
Competent: There is an increased level of management skill acquisition. Despite the increased experience, there is still some inflexibility especially with new experiences. There is some difficulty with multi-tasking at times. Planning is still necessary to limit unexpected outcomes but the nurse manager is more aware of resident and family responses to certain situations. The competent nurse manager is more confident with routine management tasks and tries to control and limit unexpected occurrences.
Expert: The expert nurse manager is confident, more involved, active with decision making, and more flexible with new situations. The manager interprets situations using tried and tested management and leadership principles, abstract reasoning and holistic processes to guide practice. At this stage, the manager builds relationships. The expert nurse manager does not only rely on rules or guidelines to make decisions but on intuition that has been developed through the years of acquired experiences and skills and anticipates the unexpected. The expert nurse has a skilled “know how” that is based on experiential learning and an intuitive decision-making approach.

NMIT T-test results NM and DON

Clinical Skills Independent Samples t-test NM and DON Group Statistics

GroupNMeanStd. DeviationStd. Error Mean
NM213.5711.0757.2347
DON/ADON204.10.8522.1906
Leadership Reflective Practice IndependentSamples t-test NM and DON Group Statistics

GroupNMeanStd. DeviationStd. Error Mean
NM213.4836.75857.16553
DON/ADON203.3472.88382.19763
Diversity Independent Samples t-test NM and DON Group Statistics

GroupNMeanStd. DeviationStd. Error Mean
NM213.4921.88581.19330
DON/ADON203.01671.09478.24480
Human Resource Leadership Independent Samples t-test NM and DON Group Statistics

GroupNMeanStd. DeviationStd. Error Mean
NM213.3905.77324.16874
DON/ADON202.9700.86639.19373
Relationship Management Independent Samples t-test NM and DON Group Statistics

GroupNMeanStd. DeviationStd. Error Mean
NM213.3122.88375.19285
DON/ADON203.08891.03267.23091
Performance Improvement Independent Samples t-test NM and DON Group Statistics

GroupNMeanStd. DeviationStd. Error Mean
NM213.037.73860.16118
DON/ADON203.2250.74736.16712
Problem Solving Independent Samples t-test NM and DON Group Statistics

GroupNMeanStd. DeviationStd. Error Mean
NM212.8095.88425.19296
DON/ADON203.0700.78210.17488
Information Technology Independent Samples t-test NM and DON Group Statistic

GroupNMeanStd. DeviationStd. Error Mean
NM212.7381.97549.21287
DON/ADON203.05001.23433.27600
Human Resources Management Independent Samples t-test NM and DON Group Statistics

GroupNMeanStd. DeviationStd. Error Mean
NM212.7998.88991.19899
DON/ADON202.9529.82247.18391
Strategic Management Independent Samples t-test NM and DON Group Statistics

GroupNMeanStd. DeviationStd. Error Mean
NM212.2030.95378.20813
DON/ADON202.2348.81180.18152
Financial Management Independent Samples t-test NM and DON Group Statistics

GroupNMeanStd. DeviationStd. Error Mean
NM211.7688.94679.20661
DON/ADON201.5988.68030.15212

Nurse Manager Interview Questions

The survey data shows that nurse managers identified financial management (budget creation, analysis, evaluation) at a novice level. Why do you think that long-term care nurse managers rated themselves as novices for financial management?

Probe: What is your responsibility for the unit staffing and operations budgets?

Also identified at a novice level was strategic management. This includes developing an annual strategic plan for your unit including identification of unit goals, development of specific projects for the unit and the ability to sell the strategic plan. Why do you think long-term care nurse managers rated themselves as novices regarding strategic management?

Probe: What is your responsibility for unit strategic planning?

The data shows that the Nurse Manager rated clinical skills close to the expert level. Why do you think long-term care nurse managers rated themselves with expert clinical skills?

Probe: What clinical skills are most useful in long-term care?

How do you manage the clinical skills of other nurses?

How do you maintain your clinical skills?

According to the survey data, the nurse managers identified the following items to be at a competent level. Why do you think long-term care nurse managers rated themselves as competent in the following? Probes (a–h): on-the-job training, in-services, previous experience

Human Resources (including interviewing, hiring, and staff orientation)

Human Resource leadership (staff development, coaching, mentoring)

Performance Improvement (including patient, workplace safety and quality)

Problem solving, Decision making, systems thinking

Do you have electronic medical records or a call bell system in the facility? Information technology (electronic medical records and call bell system)

Relationship management (communication skills – how you communicate with peers and staff, team dynamics, conflict management, and negotiation)

Diversity (ability to work fairly with differences in staff or residents – race, gender, religion, sexual orientation, generational)

Leadership reflective practice (constant state of learning)

NM Interview Themes and Supportive Quotations.

Qualitative ThemesSupportive Quotations
Aloneness“I've found that it's challenging and its aloneness, I mean the fact that you are so disconnected at times from nurses within other settings.”
“You are it.”
“The Nurse Manager realizes that she is responsible for the care of all the residents on the unit, knowing that the LPN's are at different levels of expertise.”
”… have to know when the situation has escalated to a point where somebody needs to be called.”
“You have to become an expert because you don't have your medical right there; I mean you have to make clinical judgments and use critical thinking even to decide to call them.”
Increased acuity levels“the residents are coming in with more challenging diagnosis, illnesses, equipment, procedures.”
The acuity level of residents “has changed in the last four or five years…we're getting more clinically complex people and we send people in and out of the hospital more frequently.”
” The physicians here trust our judgment and rely on what we see and report to them. I guess we're just pretty darn good.”
Intuition/gut feeling“…knowing how”
“It's like intuition … just by looking … into their eyes, just their facial expressions you just know something isn't quite right.”
“You get more expertise the longer you're a nurse.”
Trial and Error“You have to make those judgment calls and you have to rely on yourself and others around you and your clinical skills” and learning “from the school of hard knocks”
“A lot of times things that are new you don't get a lot of training for, you just kind of learn by doing … I had seven years of learning on my own.”
“If it's going to be something that's creating discomfort because I did it this way, and I was very uncomfortable because I didn't like the results that I got, I'm going to do something different.”
“We pretty much have to make our own decisions … and we're expected to solve our own problems … we are expected to be self sufficient and solve the problems on our floor.”
“you just learn from your mistakes, you learn from new experiences, you learn from other Nurse Managers who've had a similar experience; if it doesn't work then you try something else.”
Laddering“…going up in the ranks…the majority of us just didn't start out as a Nurse Manager … a lot of us were CNA's, LPN's, and RN's.”
“We've done all the hands-on.”
Peer support“I did follow her [peer nurse manager] for a couple of days and I took her ideas and some that I had of my own and put together some things.”
“We always ask each other, we always help each other in different aspects of difficult situations.”
“We have a couple Nurse Managers in the building that have been here for 30 years and one of them I just adore and if I have questions or concerns … I'm on her doorstep.”
“Even where I used to work, I was a peer because I was like the one with the most experience…a little bit of support that you don't get at this level…you have to create it.”
“I usually try to handle it myself but as I have said if it's a real tricky sticky wicket I usually go to the Director of Nursing or Assistant Director to get a little guidance.”
Constant State of Learning“One of the things I always love about nursing is every day I'm learning something new.”
“I can't direct staff to do things if I can't do it myself, and so I have to have the experience of doing it.”
“You need to learn because everything is changing”
“We do have certain things we do every day so if you don't switch it up and you know kind of recharge yourself the resident is going to get the end result of that.” “Be proactive and you have to want to learn constantly, that only makes it better. You can't have the same style as you had twenty years ago; it's not going to work.”
“I think that you have to learn in the role to have self-worth and to be comfortable with your decisions and to feel competent.”
Training“You don't get a lot of training…you just kind of learn by doing”“When you come in at that level as a Nurse Manager… you get just the bare minimum basic general orientation… there's no formal classes.”
Training no, not a lot…Just experience, you learn from one instance to another what worked and hasn't worked.”
“I started by learning the basics, I asked a lot of stupid questions, did a lot of research, I mean basically I trained myself.”
“You just kind of learn by doing.”
Resident Priority“We're all here for one purpose and that's to take care of the patient.”
“to be confident with what I'm doing to be able to manage and to be the leader of the unit.”
“looking at patient outcomes and what did we do good, what did we do that we could improve upon ... how can we make this work better …we were constantly relooking at that, and to see … how can we get this better?”
“You have to look at what they bring to the table from life experience and from culture. I really feel that every resident has reasons why they may be the way they are.”
“…long term care it's not just the patient, you have the whole family … so you need to make a wise decision to be able to work with family and to help residents.”
Tough Job“I think the job is more challenging now, there's more problems now. Families are more educated and question more.”
“It is a very demanding job … because you always have to expect the unexpected. There are emotional things that happen with staff, with residents, with family members.”
“You get beat up constantly. If it's not staff or administration, or a resident, or a family member … who's angry and where does that anger get directed …it gets directed a lot at the Nurse Manager.”
Job Expectation“The Nurse Manager in particular in long-term care has to be at the top of the game. They have to be strong clinically; they have to be strong with their leadership abilities and critical thinking.”
“It's part of what we have to do every day and so you do become pretty good at problem solving, trouble shooting and trying to be creative.”
“The safety on a unit, it falls on the Nurse Manager because she needs to make sure that the residents are safe and the staff is safe.”
Staff diversity“…working with the different cultures that you're not familiar with and sitting down and talking with them when they get together … listening to them talk and asking questions and just spending time with them.”
“It can be hard for people to work with people that are different from them, and that's something that continually needs to be taught, encouraged and tolerated.”
“There's a different level of how they live from day to day…just their home situations, their beliefs and their values are different … if you understand it or try to understand it then you have a better connection with them.”
“An extremely diverse populous, whether it be residents or employees, and they are all very culturally different and you have to be able to understand that.”
“You have to learn how to adapt yourself in the different cultural diversity … we have to be respectful of all of them, allow them to express their thoughts and opinions and accept them”
Coaching/Role Modeling“You coach, mentor, every day, you teach, supervise, you assist them, you work with them.”
“I think a big huge part of what a Nurse Manager's job is coaching her staff, and again, I think it's just because there is nobody else so you do it.”
“I love to teach, I love to coach, I love to watch somebody just blossom and take off … look at weaknesses and strengths.”
“One of the biggest parts of my job is education, it's got to be ongoing; something is brought to your attention, you have to stop and you have to educate.”
“You try to teach as much as you can along the way, but a lot of it is guidance, ongoing guidance and teaching as a nurse manager.” It is the most important job that you have, is to get everyone through the process they come here to live, and they're going to pass away with us, and how do you do that from beginning to end so that everyone is comfortable?”
“You have to be able to do everything that they do out on the unit…so you could best educate and mentor them.”
Communication“I still feel that it's my responsibility…to make sure that the team is following and doing what they're supposed to be doing.”
“They don't understand each other's ways, but I try to keep the unit open and freely talking about things.”
“I guess I just like to help people, and by creating a good floor and team I know they'll be helping the residents the way they should be helped and that gives me satisfaction.”
“We have to be able to communicate with the staff, because if you can't communicate with them and you can't bring yourself to their level wherever they are it's not going to happen.”
“I believe in good communication because I tell people you can't do anything if you don't know what I expect.”
Relationship Development“You need to be sometimes the balance between the staff and families…you need to be able to listen. They trust you to have patience and listen.”
“People come to work they have all types of problems … not always just the surface, it's things that are deeper and I think you just need to sit down and try to see where the person is coming from.”
“I found the hardest when I first started as a Nurse Manager leader, conflict management, even confrontation, speaking with somebody. I still find that very difficult, to this day.”
“You're maintaining all your relationships with all the people above you, below you, and beside you … because you do that all the time you have a level of confidence and competency.”
Visibility on unit“We all joke at the end of the day how our chest hurts and we have no breath left and it's because we're talking all day to everyone on every level and every discipline.”
“When they do have a fall, go in, check the room out, check the environment…and make sure everything is safe, not for the resident but for the staff as well.”
“I can go into a room of a whole bunch of residents … and I can see the danger areas. I can see who's at high potential of falls … things that are unsafe that somebody else might walk by.”
“I guess I just like to help people, and by creating a good floor and team I know they'll be helping the residents the way they should be helped and that gives me satisfaction.”
“If you don't visibly look, see, hear, and smell you're not going to get past the gate because you will miss something.”
Strategy and budget by others“I don't know as the Nurse Manager feels like she has an awful lot of impact in being able to drive a lot of the change.”
“…difficult to be able to look long range because of the fact you're dealing with day–to-day things.”
“There are a lot of things that I need to go through if I want to make some big changes … I always have to report to my Assistant Director of Nursing (ADON).”
“basically keep my residents happy, to be deficiency-free.”
“you're accountable for your monthly variances whether you've been over or under, but yet you don't have any control over it.”
Personal Values“People have always had the opinion that gerontology was a lesser field … we are really good at what we do and we're here because we want to be here, not because there's no other place that would hire us.”
“we're always making decisions; it seems like that's where the buck stops, the nurse manager level … it just comes with the territory.”
“you do it because you enjoy the patients or you love the people. I don't think you do it for the money.”
“I have a lot of respect for anyone that does what I do. I think they're the best nurses in the world … I don't think anybody … has a clue what it takes to do this job every day.
“People always used to say when they needed to start winding down their life and kick back a little bit they'd go to long-term care. Well, I never found that it's laid back.”
” It's a hard job. You have to keep the residents happy, the families happy, you have to keep the staff happy, keep medical department happy, nursing administration happy and the State Health Department happy and when you get all that done, a little happiness for yourself”
“long-term care nurses…know their patients inside and out, left and right.” “A Nurse Manager in long-term care is a specialty in its own.”
“looking at patient outcomes and what did we do good, what did we do that we could improve upon ... how can we make this work better …we were constantly relooking at that, and to see … how can we get this better?”
Final JourneyIt's not just everybody is here to die. Everybody is here to live and experience complications along the way that we must try to figure out how to deal with, but it's a different way of thinking.”
“long-term care to me that's their home…their quality of life. That to me is you want to make their last few years the best that they can be.”
“Living the life anywhere from five years to three days with the residents and their families, and going along step by step and sharing their feelings and their experiences … and just being part of their life more than just a hired worker.”
it's the end of the life; you're going to journey through the final stages where you might not do that in the other settings. So you connect with families in ways that you wouldn't necessarily in other settings.”
Authors

Dr. Dever is Associate Professor, Wegmans School of Nursing, St. John Fisher College, Rochester, New York.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Kathleen H. Dever, EdD, MS, RN, Associate Professor, Wegmans School of Nursing, St. John Fisher College, 3690 East Avenue, Rochester, NY 14618; e-mail: kdever@sjfc.edu.

Received: January 12, 2017
Accepted: February 04, 2018
Posted Online: April 02, 2018

10.3928/00989134-20180322-01

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