52 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004
Diana S. Contino is the owner of Emergency Management Systems, Inc, in Laguna Niguel,
Calif, and a consultant with MedAmerica. She has more than 16 years of leadership and
management experience and provides acute care operational assessments, process redesign,
and financial consulting. She is experienced in applying profiling tools, establishing collaborative relationships between nurses and physicians, and eliminating barriers between
nurses and financial professionals.
evidence-based research in the
development of healthcare leaders.
The evidence-based research that is
available is largely descriptive and is
poorly translated into healthcare.
In this article, I provide a compilation of practical managerial skills
for critical care nurses in formalized
managerial roles, as well as leadership
skills that are useful for all nurses.
These skills are based on my managerial and leadership experience, the
findings of numerous experts, and
healthcare and business resources.
The highly divergent and
dynamic leadership skills described
herein mirror the responsibilities of
critical care managers. The skills also
illustrate the need for open-minded
leaders who collaborate with colleagues and peers to prepare for and
respond to the multifaceted challenges that arise every day. For purposes of clarity, the leadership skills
are grouped into 4 main categories:
1. organizational management
3. analysis/strategy, and
Included in each of these categories are key skills and abilities that
make leaders effective. Although the
categories are an artificial separation
of skills that intertwine and overlap,
the skills are discussed separately for
the purpose of explaining each skill
and demonstrating its applicability.
Despite the expansive nature of this
topic, the examples are brief; the references cited provide additional
information and resources.
Administrative teams can use
these leadership skills as the foundaDiana S. Contino, RN, MBA, CEN, CCRN
The healthcare workplace is
comparable to what a person sees
when looking through a kaleidoscope:
as the moments pass, an endless
variety of patterns emerges. Undesirable patterns that have materialized include the widely publicized
shortage of nurses in the workforce
and the high rates of turnover among
nurses. Healthcare organizations
increasingly depend on recruitment
and retention of nurse-managers to
reverse these trends.
Critical care nurses become leaders through a variety of routes, many
of which do not include formal managerial training or education. To
produce positive results, critical care
leaders need effective strategies to
manage departmental operations
and inspire staff. One strategy used
by chief nursing officers, professional
nursing associations, and employers
is to design and implement formalized critical care leadership and
managerial training programs that
are evidence based and results oriented. In Leadership Research in
Business and Health Care, Vance
and Larson1 report an underuse of
Knowledge, Skills, and
Aptitudes Nurses Need to
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-
2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].
tion to create competency-based job
descriptions and development programs for nurse-leaders. Table 1
summarizes the skills reviewed in
the following paragraphs.
Healthcare businesses can benefit from examples of other successful
organizations. The book Built to Last,
a study of successful corporate habits,
indicates that continuity of leaders
and ongoing leadership development
contribute significantly to the success
of an organization. Organizations and
their shareholders benefit if employees are taught to manage time, information, human resources, change,
revenue and expenses, information
technology, and equipment. In a
follow-up research book, Good to
Great, Collins3 describes a level 5
leader as one who builds enduring
greatness through the use of personal humility and professional will
to mentor others to do the right
thing, one who takes responsibility
for failures while giving credit to others for their success, and one who
relies on inspired standards to motivate others. He states that level 5
leadership is one of the key determinants of organizational greatness.
The essence of great leadership is
effective management of oneself
and others in response to a variety
of situations. Therefore it is essential that leaders learn to manage
their emotional response to a variety of situations and others actions.
How staff members perceive
nurse-managers is critical to recruitment and retention efforts. Wieck
et al4 suggest areas for the betterment of current and future leaders.
They indicate that the entrenched
and emerging workforce wants leaders who demonstrate honesty,
integrity, and optimism. Workers
want good communicators who are
receptive to others and who are
motivational, fair, approachable,
and empowering.4 Results of
Reversing the Flight of Talent, a
survey of 1600 staff nurses conducted by the Advisory Boards
Nurse Executive Center, indicate
that nurses want to work for effective nurse-leaders.5 Of the nurses
surveyed, 84% had considered leaving their jobs because of dissatisfaction with their direct managers;
however, only 43% of nurses surveyed who were very satisfied with
their managers had still considered
leaving nursing.5 Incorporating
research findings on healthcare and
business leadership into educational programs for nurse-leaders
will expand and enhance their leadership skills.
Effective leaders use successful
strategies for time management.
Often leaders allow minutes and
hours to be wasted on nonessential
tasks such as opening mail, filing,
CRITICALCARENURSE Vol 24, No. 3, JUNE 2004 53
Table 1 Nurse-leader competencies
Organizational management skills
Manages time and prioritizes work appropriately
Manages information to benefit the units operations and personnel management
Manages human resources through the promotion of individual and teamwork
involvement and in accordance with policies and procedures
Mentors and works collaboratively with members of all disciplines
Manages and implements change to improve operations
Manages revenue and expenses according to budget
Manages technology and equipment to reduce errors, gain efficiencies, and comply
with budget targets
Effectively communicates the units goals and objectives and how they fit into the
hospitals mission and vision
Communicates and supports the organizational structure and promotes trust and
honesty through words and actions
Sets and meets or exceeds personal, career, and education goals
Mentors staff in setting and meeting personal, career, and education goals
Communicates and promotes continuous learning
Communicates and promotes effective change
Data/operations analysis and strategic planning skills
Uses appropriate internal data to evaluate operations
Looks for solutions and new business opportunities both internally and externally
Uses effective critical-thinking skills and decision-making strategies
Evaluates and anticipates the effect of change before implementation and responds
appropriately to unexpected outcomes
Plans and evaluates the units business plan
Creates opportunity for employees
Creates a vision for the unit or division
Creates value for customers
Creates quality through continuous improvement, error reduction programs, and
customer service initiatives
Creates effective relationships with peers and business partners
54 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004
and responding to noncritical
requests from others. Effective leaders use self-discipline to organize
these tasks and assign priority to
projects that produce results. By
learning from management experts
such as Stephen Covey, nurses can
perfect their time management skills.
In his book, The 7 Habits of Highly
Effective People,6 Covey eloquently
describes a time management matrix
that provides a guide for understanding the relationship between important, not important, urgent, and
nonurgent activities (Table 2). This
tool encourages leaders to focus most
of their time on nonurgent activities
(quadrant II).6 For example, a directors budget (quadrant II planning
and quadrant I deadline-driven projects) is due in 3 days and a friend
calls to get advice on vacation plans.
The director correctly responds by
asking the person (quadrant III interruptions and quadrant IV some phone
calls) to call the director in the evening
at home. If a leader participates in
activities in the upper right corner
of the top part of the table, the results
outlined in the upper right corner of
the lower part of the table will ensue.
Planning will result in vision and
perspective; whereas the continual
management of crises will result in
stress and burnout (Table 2). A leader
can use this matrix to prioritize tasks
and responsibilities, reducing time
wasted on nonurgent activities. This
example is an easy distinction; however, managers face much more subtle choices, making the disciplined use
of the matrix even more important.
A leader can use time efficiently
while building staff members selfesteem, as exemplified by the concept
of 1-minute praise described in the
One Minute Manager.7 Finding creative, quick, and individual ways to
thank staff members, colleagues, and
customers is an important leadership
skill. Effective time managers find
easy ways to acknowledge staff, such
as keeping thank-you cards tucked in
their organizer or putting reminders
in their personal digital assistant.
While waiting for meetings to start,
leaders write thank-you notes to staff
members and others who exhibit
exceptional behavior and mentoring
activities. The personal acknowledgment of staff members builds morale
and improves retention.8
Delegation skills are critical to a
leaders ability to manage time. Leaders do not have to do everything.
Their role is to ensure completion,
monitor ongoing progress, and
affirm that interventions produce
results.9 A leaders effectiveness is
maximized by assigning appropriate
tasks and projects to staff nurses
and other administrative support
personnel. Ales10 describes a 4-step
process that guides readers through
the art and science of delegation:
choosing a task that can be delegated,
assigning it to the right person,
communicating clear instructions,
and soliciting feedback.10
Table 2 Time management matrix
Interruptions, some calls
Some mail, some reports
Proximate, pressing matters
Recognizing new opportunities
Trivia, busy work
Some phone calls
Important Not important
Fired from jobs
Dependent on others or institutions
Reprinted from Covey,6 with permission from Franklin Covey Co (www.franklincovey.com). All rights
reserved. Not important
Always putting out fires
Short term focus
Sees goals and plans as worthless
Feel victimized, out of control
Shallow or broken relationships
Managing information is critical
to a leaders success.9 Without timely
statistics and outcomes data, managing in accordance with budget targets and performance measurements
is difficult. Effective leaders are able
to share statistical and outcomes
data with staff members to gain the
members participation in meeting
budget targets. Additionally, comparing internal (benchmark) data
with data from similar organizations is helpful. Resources such as
the National Database of Nursing
Quality Indicators11 provide data on
a variety of benchmarks such as
nursing skill mix, nursing hours per
patient day, pressure ulcers, and falls.
The Advisory Board12 is another
resource that showcases a variety of
best practices. Collaborating with
colleagues, with peers, and within
professional organizations is another
way to gather information about
trends and successful solutions to
operational dilemmas. Critical care
nurses manage large amounts of
complex data about patients, and
nurse-managers are required to do
the same with operational data.
Managing Human Resources
An enormous part of the nurseleaders role is the management of
human resources, specifically nursing
resources. Considerable attention is
paid to the complexities of understanding people, because just as with
a disease, it is easier to implement
interventions if the diagnosis is
known. Geddes et al13 conclude that
a need exists for fiscal accountability, quality-enhancing management
strategies, and personnel management. How to involve and engage
critical care nurses should be included
in the training of nurse-leaders.
Kouzes and Posner14 concluded that
genuine caring for people (critical
care nurses) is at the heart of effective
leadership. How critical care nurses
interact with patients and with colleagues directly affects not only satisfaction among customers and
employees but also the safety of
patients. Therefore, teaching critical
care leaders how to manage human
resources is vital to an organizations success.
The human resources department
and hospital policies guide nurseleaders in decision making. The current nursing shortage and high
turnover rates indicate a need for
collaboration and close working
relationships with human resources
professionals. Those professionals
can track the reasons for high turnover, vacancies, and/or excellent retention of critical care nurses. Mark and
Critten15 suggest that the future focus
of human resources departments
should be organizational central
intelligence and the facilitation of
organizational learning and creativity.
Siddiqui and Kleiner16 reviewed
human resources operational management and concluded that healthcare organizations should adapt the
latest methods used by human
resources professionals. These methods include encouraging diversity in
the workplace, promoting from
within the company, and cross-training personnel whenever possible.16
Ridenour17 reports that leadership
competencies influence patients outcomes, continuous learning, relationships with customers, use of
resources, strategic planning, and
compliance. How employees are
treated and mentored is critical to
retention efforts; therefore, management training should include interpersonal skills and strategies for
responding to different personalities.
Leaders learn strategies to create
a culture of understanding through
the use of personality-profiling tools.
Effective profiling tools are nonjudgmental, accurate, applicable,
and easy to understand. One of the
best-known tools is the Myers Briggs
Type Indicator.18 This tool is an
instrument for measuring a persons
preferences by using 4 basic scales:
3. thinking/feeling, and
Combinations of the different
preferences can result in 16 personality types. An understanding of the
personality type is crucial to a leaders
ability to empathize with another
person and what that person may
The Keirsey Temperament
Sorter19 is a profiling tool based on
the theory that every personality
has 2 sides. Temperament is partially
inherent at birth, whereas character
is a set of learned habits or skills.
With this tool, temperaments are
sorted into 4 basic categories with
multiple combinations. Persons with
artisan temperaments are predisposed or born to impulsive action;
those with guardian temperaments,
to responsible service; those with
idealist temperaments, to personal
development; and those with rational
temperaments, to objective analysis.
The survey consists of 70 questions
and results in a persons profile of
combinations. The temperament
analysis is a method for understanding a persons character through the
identification of the persons learned
habits and skills.
CRITICALCARENURSE Vol 24, No. 3, JUNE 2004 55
56 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004
A newer profile that is nonjudgmental, accurate, applicable, and
easy to understand is Time Typing.20
The titles Past, Present, and
Future are metaphors for physical
time and are used to explain that
opportunity, knowledge, and control are reference points from which
persons interpret situations and
make decisions. This model also
helps persons understand what
motivates them, how they gain selfesteem, how they communicate,
and what types of reward systems
Persons of the Past type are
attuned to information and risk aversion. Past-oriented people are very
comfortable with gathering and analyzing data and they seek the truth.
Persons of the Present type are
attuned to control. They create organization out of chaos and excel at creating and following a plan. They
have patience and strive to create
stable harmonious environments,
often by maintaining the status quo.
Persons of the Future type are attuned
to opportunity. They thrive on chaos
and change. They dont want to miss
an opportunity so they dont turn
anything down but will quickly abandon things that wont work. Theorists
think that people have some characteristics of all 3 types, but everyone
has a primary or dominate perspective or way of looking at the world.
Time Typing does not have complex combinations of types that
require the learner to focus more on
understanding the personality profile than understanding a persons
decision-making style. It is an ipsative
tool that compares the person to
himself or herself. Most of the other
profiling tools are normative, ranking the person against others and
creating a judgmental environment
that contributes to selection bias.
Time Typing also includes tools to
help evaluate team dynamics and a
decision wheel that helps leaders
facilitate decision making. Its simplicity makes it a powerful corporate
training tool. Table 3 is a comparative representation of the 3 types of
tools: Myers Briggs Type Indicator,
Keirsey Temperament Sorter, and
Understanding cultural norms
and diversity is just as important as
understanding individuals. Dreher
and Macnaughton21 contend that
cultural competence is really nursing competence. As communities
become more diverse, it is important that leaders adopt strategies to
teach, provide feedback, and motivate persons from different cultural
backgrounds and different skill
mixes. For example, asking patients
to participate in focus groups and
report their feelings and perceptions
of their treatment allows managers
and staff to see the world from the
patients eyes, including the patients
cultural views and norms.
Leadership mentoring bridges
the regulatory and subjective aspects
of human resources management
through the pairing of experienced
leaders with novice leaders. To illustrate a type of mentoring, Montgomery22 presents a descriptive
method whereby an experienced
professor mentors a doctoral student in the needed leadership and
administrative experiences. The
mentoring of new critical care managers by the chief nursing officer
should occur over time and is
enhanced through the resolution of
increasingly complex situations.
Table 3 Comparative profiling tools
Meyers Briggs Type Indicator
A profiling tool that provides a way
of describing people’s personalities
by looking at their preferences on
4 basic comparative scales
8 preferences resulting in 16 types
Keirsey Temperament Sorter
A profiling tool based on the premise that there are 2 sides to personality: temperament (inherent at
birth) and character (learned
habits or skills)
4 basic temperaments resulting in
Opportunity, knowledge, and control
are the different reference points
from which individuals interpret
situations and make decisions.
3 types: 1 dominant type and
2 less dominant types
Critical care leaders must
respond to new regulations, changing economic conditions, consolidations, and/or hospital closures.
Because of the rapidly changing
external environment, it is increasingly important to understand how
leaders anticipate and implement
change.23 Nurse-leaders exert significant influence in the change process.24
Menix25 states that without appropriate educational preparation nurse
managers may not have the competencies to effectively manage accelerated change. The article by Menix
is part 1 of a 2-part review of the literature and Delphi validation study
on change management. (The Delphi method is a process in which a
questionnaire is distributed to
experts who independently complete
it; the results are evaluated to determine the likelihood that certain
events may occur.) Critical care
nurses can use this evidence-based
information to educate each other
about change. Nagaike26 applies the
categories of change, identified by
change management expert
Anthony Robbins, to healthcare
organizations and concludes that
clear communication, accurate data
and flexible plans are vital to managing effective change and providing
Implementing and responding to
change requires that leaders be able
to evaluate the change process. Demings model of change, Plan-DoStudy-Act,27 is prevalent in healthcare
1. Plan: identify and clearly define
2. Do: develop and implement a
3. Study: analyze the problem,
identify the root cause, map the
process and what affects it.
4. Act: evaluate the results and
make modifications if necessary.
This concept was first discussed
by Skewhart28 in 1939 and then made
famous in the 1950s when Deming
encouraged the Japanese to adopt it
to promote continuous quality
improvement.29 Carney30 presents a
change management model that
enables leaders to evaluate the
process. Understanding why nurses
resist or accept change enables a
leader to communicate why change
is necessary and to mentor others
through the change process.
Managing Revenue and Expenses
International studies indicate a
global need for financial education
for nurse-leaders.15,31,32 Courtney et
al31 cite financial management as 1 of
the 3 top areas in which development
is most needed. Nurse-managers
must have basic knowledge of financial management. Interpreting
financial statements, understanding
performance ratios, and recognizing
the time value of money are essential
when financial forecasts and cost
implications for business plans are
being estimated. Understanding cash
flow from when a patient registers
to the point of collection of the
patients bill facilitates the design of
Leaders must understand how
their organizations formulate budgets
and how their chief financial officers
prioritize capital equipment purchases and expectations for managing
in accordance with a units budget. To
compile a capital budget, managers
must understand the financial implications of leasing versus purchasing,
the expected useful life of equipment,
and estimated maintenance costs.
Understanding how to calculate a
return on investment when proposing new technology, such as computerized documentation systems,
enables critical care leaders to conduct cost analysis of different systems and options. The chief financial
officer may not take proposals for
new technology, additional staffing,
and/or equipment seriously unless
financial justifications are included.
Critical care leaders should collaborate with the finance team to
understand projections for activity
of the health plan, changes in suppliers prices, and demographic
forecasts for the community. This
collaboration is crucial to budget
planning.32 Forecasting the number
of patients expected, salaries, and
supplies can be challenging, especially because the number of
patients treated depends on external factors. It is important to know
the cost per unit of service so that
staff and supplies increase as the
number of patients increases.
Knowledge of expiring supplier and
provider contracts helps leaders
anticipate the effects of budgeted
rates and numbers of patients. Collaboration of nurse-leaders with
financial staff helps improve cash
flow and the organizations financial health.
A basic understanding of information technology is essential for
critical care leaders.9 Todays
means leaders must understand
how a hospitals information systems work and how to use technology to make processes and
CRITICALCARENURSE Vol 24, No. 3, JUNE 2004 57
operations more efficient. Regulations such as the Health Insurance
Portability and Accountability Act
of 1996 affect computerized nursing
documentation tools and protection
of patients information.
Nurses who have mastered technology can devise technological
interfaces to gather statistical data
that assist in efficient management of
critical care units. Technologically
savvy nurses can use Web technology
to make educational materials and
programs, such as videoconferencing
and Webcasts, easily accessible for
patients and clinicians. Critical care
nurses can use software on their wireless personal digital assistants to look
up, verify, and calculate medication
dosages or concentrations of intravenous infusions to reduce medication errors. Wireless personal digital
assistants and laptops improve fast
and efficient communication. Enabling patients televisions with Internet
access to facilitate the dissemination
of disease-specific education for
patients enhances the discharge
process. Technological advances surround critical care nurses and nursemanagers. Harnessing technology in
conjunction with current research
findings improves operational efficiencies and patients outcomes.
Each organization has unique
operational issues and managerial
supports. To successfully overcome
the challenges faced by an organization, nurse-managers must work
with supervisors to hone the necessary leadership skills.
Communication occurs through
speech, nonverbal signals, and written documentation. It is essential
that leaders disseminate and interpret information quickly and accurately. A 2-year study33 of Chilean
nurse-leaders suggested that leadership is characterized by exerting a
positive influence on others through
good communication. At the root of
effective communication is delivering
the message in such a way that the
listener will hear it. The concept of
seek first to understand, then to be
understood is one of The 7 Habits of
Highly Effective People.6 It is very
important for a leader to understand
what employees need and want, as
well as what motivates them. Simulation and role-playing are effective
methods for improving communication skills.34
Leaders should be able to inspire
passion for and commitment to an
organizations mission by communicating a vision. The mission is what
the organization strives to accomplish; in other words, the reason the
organization exists. The vision is the
creation of a picture of how the
mission is going to be accomplished.
Vision is also about understanding
how to rally people around an idea.
All operations, education, goals, and
strategies should be linked to the
vision and should fit in with the
overall mission. For example, a hospitals mission could be to provide
access to optimal healthcare in our
community. The vision is that the
health system be central in the
communitys efforts to be healthy,
by creating caring environments for
patients and clinicians by using
technology and efficient operations.
An example of a critical care divisions
vision is interdisciplinary collaboration to promote a caring and
error-free critical care environment
and delivery system.
Understanding different theories
of organizational structure is important. It is a myth that there is a single
right or best organizational structure.
Organization is a tool for making
people productive when they work
together.35 To manage decisionmaking processes, the military uses
command and control, whereas
other organizations use self-governance models. Organizational structures like command and control
work effectively in crisis or disaster
management situations because decisions must be made quickly and
there is little time for discussion.
Collaborative and team structures
are effective for improving processes
and designing new programs. Effective communication of standards,
responsibilities, and rewards translates into improved performance.8
Events such as the Enron debacle
highlight the need for organizational
structures and communication centered on rewarding integrity. Promoting the obfuscation of actual
practices during surveys or billing
audits sends the wrong message and
often exposes facilities to whistleblower lawsuits. In a recent study,36
Arthur Brief, a professor at Tulane
Universitys Freeman School of Business, found that 47% of executives
were willing to commit fraud by
understating write-offs to improve
the profit outlook. Persons in subordinate roles often comply with their
supervisors because most organizations are structured to produce obedience.36 Leaders should promote
58 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004
trust and integrity through honest
and factual communication.
Continuous learning is essential
at all levels of nursing, and learning
about communication improves
teamwork and reduces errors.37 Lawson37 recently reported that communication styles differ significantly
between nurse practitioners and
physicians. Lawson encourages
providers to examine communication styles to help develop skills necessary to provide patient-centered
care. An example of using communication to promote error reduction is
a program termed MedTeams,38
which focuses on use of self-discipline
to develop behaviors that promote
patients safety. The program includes
identifying verbal cues that help
improve communication between
physicians and nurses, such as restating or reading back verbal orders. The
members of the emergency department at South Coast Medical Center
in Laguna Beach, Calif, also use the
phrase may I speak freely as a clue
that the nurse, physician, or technologist is going to question the actions
of the other person. Staff members are
encouraged to question anything they
feel is not quite right. This freedom
to question is based on the premise
that humans are fallible and that it
takes teamwork and systems to reduce
errors. Encouraging employees to set
career goals, including opportunities
to improve communication and interpersonal skills, facilitates continual
professional growth of employees.
The healthcare industry is funded
in part with government monies;
therefore, organizations are subject
to considerable regulatory oversight.
Regulations, laws, strategies, and
technologies change frequently, and
great organizations use the knowledge of change management to
implement change successfully. The
article by Weber and Joshi39 that
summarizes the information in current business and healthcare publications about how change occurs at the
individual and organizational level is
an excellent resource for nurses. Critical care managers need to communicate frequently with staff to reduce
the stress of a transforming environment. Timing is everything. Teaching
leaders to recognize when employees
are overwhelmed and how to intervene to improve the situation is
essential.40 Communication is a critical managerial skill, and when effectively used during the change
process, it is exceptionally valuable.
A key leadership responsibility is
communicating effectively with others. Inspiring and leading critical care
nurses can be a powerful result of
cogent communication. Therefore,
nurse-leaders must continually
enhance and improve their understanding of efficacious communication mechanisms.
and Strategy Skills
It is important to know how to
analyze internal and external data,
use effective decision strategies, analyze change, and formulate a business plan. In their publication
Reversing the Flight of Talent, the
Advisory Board, Nurse Executive
Center5 states that the top 3 drivers
of nurse departure are compensation, scheduling options, and intensity of work. Leaders must be able to
assess external studies, articles,
reports, and best practices in order
to identify areas for improvement
and potential solutions. A leader
should be inquisitive and ask questions that have not been asked
before.35 Critical care nurses routinely use analytical and problemsolving skills to improve patients
outcomes. Similarly, critical care
managers use their analytical and
strategic skills to improve operational outcomes.
Analyze Internal Data
What data do you need and how
do you collect it? Leaders should be
able to answer these 2 questions.
They should also be able to convert
an organizations goals and challenges into a plan of action. For
example, a team is assembled to
analyze how a unit is processing
patients from admission to discharge. The members of the team
review data and outline the key
drivers that are influencing the
processes; then they review the literature and network with colleagues
to determine the best practices. The
team leader guides the team by
ensuring that the members are
meeting or exceeding expectations
and operational goals in regards to
the admission and discharge of
Strategize External Opportunities
External resources can guide
critical care nurses in improving
operational processes. The Leapfrog
Group,41 a national group of
employers studying and responding
to quality healthcare issues, was created to help save lives and reduce
preventable medical mistakes by
publishing hospital performance
60 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004
information so that consumers can
make informed choices. For example, the group promotes contracting
with critical care intensivists to
manage admissions to intensive care
units. Mortality rates are significantly lower in hospitals with intensive care units managed exclusively
by board-certified intensivists.
A critical care clinical nurse specialist or nurse practitioner
employed by the intensivist group
can facilitate early discharge when
the physicians are not immediately
available. These nurse practitioners
often work with multiple organizations discharge processes and, on
the basis of their nursing experience, can evaluate the different discharge methods and brainstorm
with staff members to improve
processes. Creating a culture of
proactive discharge planning
through the evaluation of best practices at other organizations is fundamental to efficient operations.
Tools such as Time Typing help
leaders understand intuitive decisionmaking strategies. There are also
tools such as the decision tree and
force-field analysis that help a group
analyze data and options when solving problems. Many of these types
of tools can be found at the Mind
Tools Web site.42 Educating leaders
and team members about different
decision-making strategies cultivates
critical-thinking skills. These tools
encourage teams to remain focused
as the teams evaluate possible solutions. Tools should be easy to use so
that staff members do not spend more
time learning the tool than evaluating the solutions.
Analyze and Strategize Change
Leaders need critical-thinking
skills to analyze and anticipate the
effects of change and respond
appropriately.24 They need to create
strategies to identify not only potential changes but also ways to position a unit to respond favorably to
change. These related needs are why
analysis and strategy are so closely
linked. For instance, nurse-managers are obligated to understand
billing and accreditation requirements in order to design documentation tools that proactively meet
the ever-changing requirements.
The implementation of ambulatory
payment classifications requires that
hospitals place a variety of codes on
outpatient procedures and treatments (eg, use of intravenous infusions, Foley catheter insertions,
radiographs). In order to expedite
the coding process, documentation
tools must be efficient for the nurses
and must facilitate accurate coding
and billing. Collaboration and criticalthinking skills are used by a units
leader and team members to coordinate the implementation of ambulatory payment classifications and to
maintain the units charge description master.43
Strategize a Business Plan
Writing a business plan helps
leaders set priorities and goals for
current operations and future
opportunities. Each leader should
manage in accordance with the
annual business plan of his or her
unit. Elements of a business plan
include the following:
Business history: The history
of the unit, division, or organization
should be included if the readers
need to know the historical perspective in order to support or approve
the business plan.
Product or service: The product
or service section encompasses an
overview of the service or product
offered. For example, the burn intensive care unit provides expert physician and nursing care in a clean and
comfortable environment that promotes physical and emotional healing as well as education for patients
and patients families.
Competition: The competition
section summarizes the strengths,
weaknesses, opportunities, and
threats of the organization or unit.
Examples of strengths are a new unit
with Internet access in each private
room or an operating room with
robotics. A weakness may be that
the physical plant is 10 years old
with semiprivate rooms, whereas
competitors have private rooms.
The profile of opportunities
includes discussion about changing
demographics. For example, a
biotechnology company with 5000
employees is opening a new office
next to the hospital, a situation that
presents the opportunity to expand
workers compensation services to
the new companys employees. The
description of threats outlines new
programs or services offered by
competitors, regulatory changes,
and new providers offering less
expensive services (eg, urgent care
centers or outpatient surgery
Marketing: The marketing section discusses the marketing strategy.
For example, one hospitals marketing strategy may be to profile its
profitable service areas, such as cardiovascular surgery, whereas
anothers strategy may be to profile
its superior customer service.
CRITICALCARENURSE Vol 24, No. 3, JUNE 2004 61
Operations and management:
The section on operations and management should highlight the unique
operational and management
aspects of the critical care unit. For
example, how and where the staff
delivers services and if the unit or
organization is superior in its performance benchmarks when compared with other units or
organizations. For example, a transplantation intensive care unit can
promote its large number of kidney
transplant recipients, the optimal
outcomes for the units patients, and
the units excellent customer satisfaction scores.
Goals and objectives: The section on goals and objectives includes
the goals of the unit or division and
the mechanisms used to measure
whether the goals are reached. For
example, a goal is to improve customer service as measured by customer satisfaction scores. The unit
will meet the goals by participating
in multiple local and national educational programs to increase staff
awareness about customer service
initiatives. On the basis of the
results, a customer service process
improvement team is chartered to
assess and redesign processes to
Financial projections: Financial
projections include the financial outcomes of the business-planning
efforts. For example, the business
plan includes the purchase of a new
computerized documentation and
order entry system. This new system
reduces errors that stemmed from
illegible writing and missed orders.
Because of the expanded remote
access, it also enhances communication with physicians and patients.
The financial projection includes the
cost of the new system, potential
cost avoidance through the reduction of liability, and personnel
reductions due to elimination of
Writing a business plan is similar to the nursing process: assessment, objective and subjective data
collection, evaluation, and planning.
How to Write a Great Business
Plan44 in the Harvard Business
Review is an excellent reference and
outlines the important points of formulating a business plan in greater
Nurse-leaders create opportunity,
value, relationships, and quality for
their employees, customers, and
organization. For example, implementing a formalized mentortraining program to increase the
retention of new graduates is a creative approach to retention. If a
manager does not have a creative
solution to a particular situation,
the manager should be able to identify these qualities in others so that
ideas for improvement are still
brought forth for evaluation and
Emotional intelligence is the
ability to manage ones emotions
while having awareness of the emotions of others. For example when a
nurse-manager jumps to conclusions or lets emotions control a situation, credibility as a leader is lost.
Responding to staff in a punitive or
irrational way is equally devastating
to a managers relationship with
staff members. Freshman and
Rubino45 highlight the importance
of emotional intelligence as an
essential skill for healthcare managers. A leader with emotional intelligence is socially aware and has the
interpersonal skills to listen to and
respond appropriately to an
employee. For example, while investigating a patients complaint, a
leader ascertains that the offending
employee was previously subjected
to verbal abuse. This knowledge
allows the leader to help the
employee understand his or her
response to the demanding patient
and subsequently make changes in
behavior to respond appropriately
to situations that elicit strong feelings of past negative experiences.
Emotional intelligence skills
enhance leaders ability to create
opportunity for their peers, employees, and customers through selfawareness and self-regulation.
It is often said that leaders are
only as effective as the employees
who work for them. Part of a
leaders role is to create opportunity
to encourage employees personal
and professional growth. Brunt46
provides an overview of the American Nurses Associations scope of
standards of practice for profes62 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004
Nurse-leaders create opportunity,
value, relationships, and quality for their
employees, customers, and organization.
sional development of nurses. Leading others by example and rolemodeling can be very effective. One
aspect of mentoring professional
development is to enable others to
act and to give others credit whenever appropriate. Mentoring
employees to be self-directed and
create their own opportunities is a
win-win goal for the individual and
Promoting collaborative practice
creates opportunities, especially in
the areas of relationships between
physicians and nurses. Freeman et
al47 present a comprehensive case
study and conclude that collaboration enhances patients outcomes. In
their study, 6 multidisciplinary
teams are profiled, and the factors
that inhibit or support collaborative
practice are extensively explored.
Create Value for Your Customers
What we want is unique, but
the means to satisfy it is varied.4
Bringing customers and the outside
world into the organization is
essential when evaluating needs of
customers and potential customers.
The driving forces of change are
often external. For example, a small
respected community hospital is
treating fewer patients than before
because the child of a prominent
citizen died of cancer and the parent donated money to fund the
construction of a new childrens
cancer hospital. Even though the
community hospital provides excellent service, it stands to lose a considerable number of patients to the
new childrens hospital. Leaders
could design seamless links between
the hospitals, creating a win-win
solution for the patients and the
Effective leaders also strive to
create value for customers through
service excellence. Pollison48
describes how one facility took its
customer satisfaction scores from
the 13th to the 82nd percentile.
Create Quality Through
and Error Reduction
The quality management office
should not be hidden in the basement and emerge only before the
accreditation survey. A focus on
quality and error reduction should
be everywhere: in the units, at meetings, and in the financial services
offices. Leaders should encourage
employees to continually challenge
the status quo. Everyone should continually use organizational process
improvement, root-cause analysis
tools, and creative teamwork to
improve processes. This goal is
accomplished by mentoring, leading by example, and designing
reward systems that encourage this
behavior. Pollison48 reported that
the hospital created excellence in
customer service through the following 8 actions:
1. committing to service,
2. committing to leadership
3. committing to employees,
4. measuring only important
5. aligning behaviors with organizational goals,
6. building individual accountability,
7. communicating, and
8. rewarding and recognizing
Critical care managers can
involve staff in many of these initiatives to improve service delivery.
Many organizations are using Six
Sigma, a data-driven method of
identifying and reducing defects or
errors. This system uses define,
measure, analyze, improve, and control
as the steps to improve operations
that fall below standards.
With Strategic Partners
Understanding the relationship
with partners, suppliers, and contractors is imperative. Organizations
must find partners with synergies,
enter into contracts with persons
and business that fill a void in the
organization, and then capitalize on
the expertise available. It is often
best to control partner relationships
with contracts, not ownership.9
Because physicians are valuable
partners, nurse-leaders should strive
to understand physicians, help them
succeed, and incorporate them into
hospital processes such as operational
analysis, error reduction, and solution identification.
Hospitals today are struggling
operationally and financially. The
reasons are complex and multifaceted. The widely publicized Institute
of Medicine report To Err Is Human49
outlines the prevalence of errors in
our systems. External organizations
such as the Leapfrog Group exist
because employers and consumers
want to spend money on quality
healthcare services and are defining
what quality means to them.
Training critical care leaders is an
effective way to proactively address
operational inefficiencies and ineffective practices in human resources. In
this article, I cite numerous management experts, theories, and beliefs
CRITICALCARENURSE Vol 24, No. 3, JUNE 2004 63
about leadership. Leaders should be
encouraged to identify their own
weaknesses and use these skills and
tools to develop and promote competency. In order to foster organizational cultures that strengthen
nurse-leaders, job descriptions for
critical care nurses and managers
should include- leadership skills and
expectations. Leadership education
and training should be one of many
initiatives related to process improvement that incorporate research, best
practices, and methods that inspire
our current and future leaders.
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64 CRITICALCARENURSE Vol 24, No. 3, JUNE 2004
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