Question

I would like you to consider various competencies of being an Nursing Home Administrator. This three page review should identify 6 competencies or skills that are essential to effective nursing home administration. Please be descriptive with your written work. Lastly, with each competency, provide a brief self evaluation of prepared you might be to meed or exceed each skill/competency.

Answer 1

Nurse managers can greatly influence the success of health care organizations

because of their management role, especially at the unit level. During the past two

decades, the nurse manager role has rapidly evolved into a position with greater authority

and responsibility. This study helps to pinpoint the current knowledge and ability

competencies important to this pivotal role based on the refinement of an instrument

previously developed by the investigator. The initial research was conducted in 1994 by

the investigator using the same instrument and was repeated in 2010 in order to compare

results and make recommendations for contemporary nurse manager role development.

The following quotes illustrate the importance of the nurse manager role in health care

organizations.

“The role of the nurse manager is critical in the provision of effective and high

quality care in any patient care delivery setting. This individual is actually the CEO of

that clinical area. She or he is accountable and responsible for patient safety and

quality. This includes all of the nurse sensitive indicators recognized by regulatory and

accrediting bodies, patient satisfaction, and financial performance. In addition, the nurse

manger represents the direct caregiver voice at nursing leadership decision-making

tables.” Linda Q. Everett, PhD, RN, NEA-BC, FAAN, executive vice president, chief

nurse executive, Indiana University Health and past president, American Organization of

Nurse Executives (AONE).

“It’s the hardest job in health care right now”, says Jane Shivnan, RN, executive

director at the Institute for Johns Hopkins Nursing, Baltimore. “This person has to

advocate up to management for nurses and other staff, but also interpret and manage organizational decisions that come down to the unit,” Shivnan says. “Because nurse

managers have such an immediate impact and such a far reach, they can influence

everything from doctor satisfaction and patient length of stay to staff nurse turnover. As

the demands of the job grow, many hospital leaders are making a subtle, yet important,

change in the nurse manager’s status by elevating the job title to “director.” She’s

talking about the ever complex nurse manager role which continues to evolve at

breakneck speed.

“It’s very challenging. You have to know about quality, patient safety, clinical

practices, finances, and material and human resource management,” says Karen

Drenkard, RN, past vice president of nursing and chief nurse executive at Inova Health

System, Falls Church, Virginal and current director of the Magnet Recognition Program.

“And you’re on call 24 hours a day, seven days a week. Nurse managers have contact

with nearly all departments of the hospital and are the bridge between staff nurses and

upper management.”

With everything that is expected of nurse managers in this role, many hospitals

are dedicating many resources to help them succeed, going well beyond traditional

manager orientation. Some organizations provide special on-site training; some send

nurses to programs offered by universities or professional groups; and some link nurses

with mentors and support groups (Hudson-Thrall, 2006). These efforts emphasize the

complex role of the nurse manager and the importance of organizations developing strong

leaders for middle management. Another way that organizations are developing

managers includes using fellowships and institutes to further develop the knowledge,

skills and abilities essential for nurse manager’s success. These provide networking opportunities and often foster working in teams on capstone projects in order to develop,

not only essential skill sets, but confidence in project management. Socialization and

emotional intelligence development are also a focus of these groups and aim at providing

novice managers negotiation and cultural awareness skills.

Excellent nurse leadership is vital to surviving and thriving in the nurse manager

role. Excellent leaders must possess administrative confidence, appropriate educational

preparation, skills to manage business deals, broad clinical expertise and a thorough

understanding of leadership principles. In particular, nurse managers hold a pivotal role

in linking the vision of the administration to actual clinical practice at the bedside.

Background and Significance

The nurse manager role is currently seen as one of the hardest, most complex

roles in healthcare (Thrall, 2006). Sanders, Davidson, and Price (1996) emphasize that

the nurse manager is responsible for translating strategic goals and objectives formulated

at the operational level into practice; thus, the position of nurse manager requires an

ability to interpret general concepts and integrate them into specific clinical and

management performance, while simultaneously determining and monitoring outcomes.

This nurse manager role is important because it is the direct link between the

administrative mission and vision, and the direct care provider. In addition, the nurse

manager role provides not only administrative and clinical leadership, but also has 24-

hour accountability for all patient care activities on the unit (Beuchlin-Telutki, Bilak,

Merrick, Reich, & Stein, 1993; Thrall, 2006). The role of the nurse manager in the acute

care nursing area is pivotal in the development and retention of staff, as well as overall

unit productivity. In total, the nurse manager has the responsibility to assure that the mission of the organization is translated into everyday practice, while assuring the quality

and efficiency of the daily operations of their unit.

This study focuses on the changes that have occurred in the nurse manager role

due to the challenges in the healthcare environment specifically in the past two decades.

Remarkably, the nurse manager role has become increasingly complex due to the shifting

environment of health care delivery, largely due to the evolution of care that has occurred

at the nursing unit-level. Tremendous transformation over the past decade includes

management of increased complexity in clinical nursing practice, shorter hospitalizations

for more acutely ill patients and pressures from compliance and regulatory agencies.

Changes in healthcare economics, advances in technology, and structural operations in

delivery systems have caused organizational transformation in healthcare institutions

impacting nurse managers (Kleinman, 2003). Nurse managers are instrumental in role-

modeling and setting expectations for staff nurses regarding the importance of high

quality, transparent and patient-focused care. Additionally, they are the conduit of

communication between upper management and the bedside staff, providing key

messages and setting the culture for their units and organization. The importance of this

role cannot be underestimated in successful healthcare organizations today.

Competencies

The term competency refers to the global ability of an individual to be effective in

work activities. A historical definition of competence as noted by Schneider in 1979

includes knowledge and psychomotor abilities, attitudes, and cognitive skills such as

problem-solving. Other definitions include fundamental abilities and capabilities to do

the job well, and use descriptive language such as traits, capabilities, intelligence, and human abilities to describe competence. Actual competencies are specific skills and

behaviors important to the role (McCarthy, Fitzpatrick, 2009, pg. 346). Some authors

believe that competencies can be learned but some are inherited, that some competencies

are skills that decrease when not used, and that some occur on a continuum. Leaders of

healthcare organizations are encouraged to identify competencies that employees need to

operate successfully in the work environment. These competencies then can be used in

selection, promotion, appraisal, and career guidance in the organization (Garman,

Johnson, 2006; O’Hearne Rebholz, 2006; Verma, et.al 2009).

Eraut (1994) defines competence as a generic term referring to a person’s overall

capacity, while competency refers to specific capabilities, such as leadership. These

competencies are made up of the attributes of knowledge, skills and attitudes. One can

refer to how competent an individual is overall or their level of competency in one

specific area (Eraut, 1994). One can also assert that overall competence is dependent

upon the level of every specific competency. It is important to be able to identify and

measure the relevant competencies that contribute to overall competence in the role, and

that each specific competency is measured by a set of valid and reliable items

representing the appropriate knowledge, skills and abilities (Eraut, 1994). Competency is

verification that required skills, processes, or concepts are done or understood correctly

as determined by an expert.

Measurements of competence can be understood as referring either to a binary

scale, to a number of sequential stages or to a level on a continuum (Clinton, Murrells, &

Robinson, 2005). The binary scale refers to where one either is competent (yes) or one is

not competent (no). An example of the sequential stages of competence is the work of Benner (1984), who outlined a five-stage model from novice to expert with competence

being stage three. Competence conceptualized as a continuum assigns a level of

competence on a continuous scale and can be used for comparisons of clusters such as

graduates or other groups (Clinton et al., 2005). A continuous scale is the most

efficacious as it provides the sensitivity often required to detect small differences

(Clinton et al., 2005).

American Organization of Nurse Executive Competency Framework

The American Organization of Nurse Executive (AONE), a leading professional

nursing organization, has provided a competency based conceptual framework of nurse

manager leadership. In 1992, AONE conducted a national study to determine the current

and predicted roles and responsibilities of nurse managers in healthcare institutions. Data

were compiled and analyzed from a random-stratified sample of American Hospital

Association (AHA) member hospitals, with questionnaires answered by chief executive

officers, nurse executives, and nurse managers from sample institutions. The results of

that study, along with contributions from AONE and the AONE Council of Nurse

Manager Board of Directors serve as the basis for these guidelines on the evolving role of

the nurse manager in healthcare institutions.

Six categories emerged including management of clinical nursing practice and

patient care delivery; management of human, fiscal, and other resources; development of

personnel; compliance with regulatory and professional standards; strategic planning;

and fostering interdisciplinary, collaborative relationships within a unit(s) or area(s) of

responsibility and the institution as a whole (AHA, 1992).

The American Organization of Nurse Executive’s (2005) Nurse Manager

Leadership Collaborative Framework is continued work by AONE which delineates the

roles of the nurse manager as managing the business, leadership, and leader development.

This model captures competencies in the areas of communication and relationship

management; knowledge of the health care environment; professionalism; and business

skills and principles, all intersecting with leadership competencies (AONE, 2005).

Communication and relationship building comprises shared decision-making, multi-

disciplinary and academic relationships and influence. Knowledge of the health care

environment encompasses clinical practice knowledge, an understanding of evidence-

based practices and outcome measurements. Active membership in professional

organizations and advocacy for ethical practice is part of the professionalism element.

Managing the business includes financial management, human resource management,

performance improvement, foundational thinking, technology, and strategic planning.

The leadership component includes human resource leadership, relationship management,

and diversity. Lastly, leader development includes personal accountability and career

planning.

Katz Competency Framework

Katz (1955) has provided a legacy conceptual framework. Katz's (1955) three-

skill approach stated that the use of each of the skills varies with the level of management

responsibility. At lower levels technical skill is indispensable to efficient operation. As

the manager moves further from actual operations the need for technical skill decreases.

On the other hand at the top level conceptual skill becomes increasingly critical for successful administration. Human relation skills are the area that is essential at all levels of management according to Katz.

Katz Conceptual Framework

Technical Skill - Understanding of a specific kind of activity, involves specialized

knowledge.

Human Skill - Primarily concerned with working with people.

Conceptual Skill- Ability to see the enterprise as a whole.

The competency model which has emerged from the business literature chosen for

this study is the Katz (1955) model. This legacy model has stood the test of time and has

a simple structure which includes three skills ranging in level of complexity and in which

circumstances they can be applied. The strength of this leadership framework is that it is

a useful way to look at leadership competencies and is applicable to the healthcare

setting.

Nurse Manager Role

Nurse managers are accountable to upper-level administration for implementation

of the philosophy, goals, and standards of the hospital organization at the unit-level.

These pivotal individuals are responsible for overseeing units of people handling the

daily operations of a unit or service line. These nurse administrators may be assigned

titles such as nurse manager, clinical coordinator, nursing supervisor, or patient care

director. They serve as the conduits between nurses and executive management,

representing and advocating for their staff. Other responsibilities vary depending on the size and function of the organization. They may or may not be accountable to a nurse

administrator at the organizational level (ANA, 2009).

Nurse managers are responsible to a nurse executive and manage one or more

defined areas of nursing services. Nurse managers advocate for and allocate available

resources to promote efficient, effective, safe, and compassionate nursing care based on

current standards of practice. They promote shared decision-making and professional

autonomy by providing input – their own and that of their staff – into executive-level

decisions, and by keeping staff informed of executive-level activities and vice versa.

Other responsibilities vary depending on the size and function of the organization (ANA,

2009).

Nurse managers also coordinate activities between defined areas of the

organization, and provide clinical and administrative leadership and expertise. They

facilitate an atmosphere of interactive management and the development of collegial

relationships among nursing personnel and others. They serve as a link between nursing

personnel and other healthcare disciplines and workers throughout the organization and

within the healthcare community. Nurse managers have major responsibility for the

implementation of the vision, mission, philosophy, core values, evidence-based practice,

standards of the organization, and nursing services within their defined areas of

responsibility (ANA, 2009).

Nurse managers are accountable for the environment in which clinical nursing is

practiced. The nurse manager must create a learning environment that is open and

respectful, and facilitate the sharing of expertise to promote quality care. The ability of

nurse managers to enhance the practice environment is critical to the recruitment and retention of registered nurses with diverse backgrounds and appropriate education and

experience (McCarthy and Fitzpatrick, 2009). Nurse managers contribute to the strategic

planning process, day-to-day operations, standards of care, and attainment of goals of the

organization. Nurse managers collaborate with the nurse executive and others in

organizational planning, innovation, and evaluation.

The Scope and Standards from the ANA (2009) for Nurse Administration states

that to fulfill the responsibilities, the nurse manager, in collaboration with nursing

personnel and members of other disciplines, performs the following:

• Ensure that care is delivered with respect for individuals’ rights and

preferences.

• Participate in nursing organizational policy formulation and decision-making

involving staff.

• Accept organizational accountability for services provided to recipients.

• Evaluate the quality and appropriateness of health care.

• Coordinate nursing care with other healthcare disciplines, and assist in

integrating services across the continuum of health care.

• Participate in the recruitment, selection, and retention of personnel, including

staff representative of the population diversity.

• Assess the impact of, and plan strategies to address such issues as:

o Ethnic, cultural and diversity changes in the population.

o Political and social influences.

o Financial and economic issues.

o The aging of society and demographic trends.

o Ethical issues related to health care.

o Assume responsibility for staffing and scheduling personnel. Assignments

reflect appropriate utilization of personnel, considering scope of practice,

competencies, patient/client/resident needs, and complexity of care.

o Ensure appropriate orientation, education, credentialing, and continuing

professional development for personnel.

o Provide guidance for and supervision of personnel accountable to the

nurse manager.

o Evaluate performance of personnel.

o Develop, implement, monitor, and be accountable for the budget for the

defined area(s) of responsibility.

o Ensure evidence-based practice by participating in and involving the

nursing staff in evaluative research activities.

o Provide or facilitate educational experiences for nursing and other

students.

o Ensure shared accountability for professional practice.

o Advocate for a work environment that minimizes work-related illness and injury.

For the purpose of this study the nurse manager title is being used and is meant to

be identified with the role of unit-level management. Organizations may refer to nurse

administrators at the manager-level by other titles, such as District Supervisor, Head

Nurse, Department Head, Shift Manager, Clinical Coordinator, Project Manager, or

Division Officer.