CASE STUDY 15-3 New Director Challenges

                Jennifer L. Embree

Mary Carroll, MSN, RN, is new to the organization. She self-identified as aSample Page servant leader and was a little anxious about her new role as the director of the critical care unit of the hospital. Two years after she earned her master’s degree in health system nursing leadership, she was determined that she was up to the challenge and would be successful, but she was experiencing some trepidation. When Mary Carroll interviewed with the new chief nursing officer (CNO), who already envisioned the organization to be on the Magnet journey, she recognized that the CNO was relationship centered and was also a transformational leader. When she reviewed the monthly budget and nurse-sensitive indicators, Mary Carroll noted the high turnover and vacancy rates (20% and 30%, respectively) on her unit, the high number of falls and hospital-acquired pressure ulcers, the high cost of overtime, and the use of traveling nurses. The mean age of the few seasoned nurses was in the upper sixties. The high number of nurses with less than 2 years of bedside experience alarmed Mary Carroll. Recognizing that the literature supports improved outcomes among nurses with higher education, Mary Carroll reviewed the number of diploma-, associate-, and baccalaureate-prepared nurses on the unit. She found that 30% of the nurses were diploma prepared, 45% were associate’s degree prepared, and 25% were baccalaureate degree prepared. Mary Carroll recognized that, without some major changes, it would be difficult to bring additional new associate-degree nurses from the local community colleges into the current hospital environment; with the current percentage of such nurses, a high turnover and vacancy rate, and poor nurse-sensitive indicators, the hospital environment was not conducive to enhancing the strength of the nursing workforce. Patient complaints were frequent, and physician dissatisfaction was high. The quality and risk managers were demanding to meet with Mary Carroll regarding quality issues, patient complaints, and current litigation. Prior to the first staff meeting, Mary Carroll spent time learning about the unit, dealing with daily operational issues, and formulating a plan to involve staff members in enhancing care on the unit while decreasing turnover and vacancy and improving patient experiences. As she observed staff members on the unit, she noted that some were cool and noncommunicative, others were frantic and claimed they were too busy to talk, and others ducked into rooms to avoid having a conversation with their new director. The first unit meeting was sparsely attended by a few seasoned nurses and several newer nurses. When she asked the attendees why they thought the meeting was poorly attended, they said that administration keeps cutting resources, everyone is exhausted, and many were out looking for positions at other hospitals. As Mary Carroll continued to ask staff members to identify issues and discuss solutions to improve the critical care unit, many barriers to patient care were identified and potential solutions were listed. As she focused on positive topics after identifying issues and seeking solutions, nurses began telling their stories of why they had chosen a nursing career and how important they felt they could be in improving patient outcomes. Some of the seasoned nurses rolled their eyes during the storytelling, and others made negative facial expressions. Mary Carroll applauded the nurses who spoke up about the possibilities for nursing and the services they could improve on their unit. Mary Carroll asked for volunteers to begin working on improving a variety of aspects on the unit. She also asked staff members what kinds of teams they thought might be helpful in dealing with the current issues they had listed and how those teams could facilitate some of the solutions that were suggested. As the meeting adjourned, the nurses expressed excitement about potential improvements and the unit issues that could be improved under the direction of their new leader. As Mary Carroll left the meeting, she maintained hope that she could empower the nurses to own their unit and improve the work environment, nurse satisfaction, the patient experience, and nurse-sensitive outcomes. She began to think about what resources she would need to engage them further.

Case Study Questions

1. Identify stakeholders who should be included in performing a needs assessment to help further identify core issues on the unit that must be addressed prior to transforming the unit culture. 2. Identify why each stakeholder should be included in the improvement process. 3. Discuss methods for identifying which stakeholders to engage, inform, and influence. 4. What are the issues in the case study? 5. What literature and theories can support resolution of the issues in the critical care unit? 6. What resources might Mary Carroll call upon to assist her in resolving the issues in the critical care unit? 7. What leadership and change theories might be helpful to Mary Carroll as she thinks about ways to improve the nursing work environment and the nurse-sensitive indicators?