Development of a new nursing organizational model
The Shands Hospital is the teaching hospital for the University of Florida Health Science Center, which comprises the Colleges of Nursing, Medicine, Pharmacy, Health Related Professions, Dentistry, and Veterinary Medicine. Shands is located in North Central Florida, is licensed for 564 beds, and has a 77.5% occupancy rate (year to date, fiscal year 1996).
What follows is a description of the process of identifying a new organizational model, communicating it to staff, moving to the new model, and evaluating it. The entire process was structured to help meet a cost management target through a reorganization while maintaining the organization’s integrity.
Following the Vision and Strategic Plan
The Shands Hospital embarked on a cost management program in 1992. The program had annual targets for each division. The target for the department of nursing and patient services (DNPS) was $4.1 million, which was 4.75% of the DNPS budget and 21% of the hospital cost management target. The DNPS Administrative Council, which included three directors of nursing, a special projects coordinator, a professional practice coordinator, and the vice president for nursing and patient services, had determined that part of the target could be met by reorganizing the DNPS. This decision was reached by comparing the management structure of the DNPS with other nursing departments, using data available from other university teaching hospitals.
As the council prepared to look at a reorganization, the members kept the vision of the DNPS foremost in mind. The vision was developed in 1992 as a leadership group effort before the cost management program was initiated. It reads as follows:
“To set a new standard of excellence in autonomous, accountable nursing practice, committed to patient advocacy and innovative patient care in a climate of trust and collaboration.”
The administrative council, besides considering the vision, also kept the strategic plan of the hospital and of nursing in mind while looking at the reorganization. For example, the hospital strategic plan called for the DNPS to take the lead in developing a coordinated care program, defined at Shands as a clinical system focusing on both quality patient care and cost outcomes and including implementation of clinical pathways. The nursing strategic plan reiterated that goal and also emphasized the continued professional development of the nursing staff.
As the council embarked on plans for this reorganization, a crucial step was to ask all the members of the nursing units to offer advice on what they felt was appropriate for a nursing reorganization. Their input was helpful because they gave specific information on each position within the leadership structure. They indicated, for example, that more supervision was needed on the evening and night shifts. Staff also expressed support for the nursing director positions and for positions devoted to continuing professional development of the nursing staff.
Besides getting input from individual nurses on the units, staff within a given position, such as the nurse supervisors, were also asked to meet as a group and offer suggestions. Each director of nursing and the leadership group reporting to them also commented on the suggestions before they were given to the administrative council. The administrative council then met and used the suggestions to develop a list of outcomes of the reorganization expected by the staff. These outcomes were:
* Supports professional practice development.
* Provides increased evening/night leadership.
* Provides resources to support improved clinical care.
* Offers advancement opportunities for staff.
* Gives increased support to unit clerks.
* Supports clinical resource utilization management.
* Provides resources for developing clinical paths.
* Fits with health care reform.
* Offers more effective fiscal management.
* Is proactive.
These outcomes suggested the following principles:
* Any changes must be patient focused.
* There must be continued support for professional practice development.
* There should be a focus on coordinated care to address continuity and needs of similar patient populations.
The administrative council worked alone for 4 days to develop the model. Each time a proposed model was discussed, the three principles suggested by the outcomes were evaluated. During this period, council members conferred with the hospital’s chief executive officer and chief of staff to keep them informed about the proposed changes and to be sure that the changes were consistent with the hospital’s strategic plan. Gaining support from the medical staff for unit-based changes that would affect medical practice was also essential. The human resources department was consulted as well because the anticipated reorganization would affect salaries and positions. Finally, the administrative council felt all outcomes had been met and that the new model addressed staff expectations.
The New Nursing Model
The pre-cost management model for the DNPS is displayed in Figure 1. Figure 2 depicts the model after reorganization. Figure 3 shows a director of nursing’s team. As illustrated in Figure 3, each director of nursing has:
1. One nurse manager for every two units instead of a nurse supervisor for each unit. The nurse manager position focuses on such management functions as budget, evaluations, hiring, and firing in addition to implementing the nursing strategic plan at the unit level and other unit operations.
2. One nurse practice coordinator for each unit to focus on professional practice. This individual focuses on coordinated care at the unit level with responsibility for developing, monitoring, implementing, and variance analysis of clinical paths.
3. One staff education coordinator for every two units instead of one unit educator for each unit. This person is responsible for unit orientation and unit educational needs, such as competency development and testing.
4. Two team coordinators on each team for the evening shift and one on each team for the night shift instead of one assistant director for the entire DNPS for the evening, night, weekend, and holiday shifts. The team coordinators provide increased evening and night leadership.
5. One coordinated care manager for each team who is responsible for implementing the hospital and nursing strategic plan for coordinated care and clinical paths.
6. One professional nursing development coordinator for each team whose focus is to work with the continued professional development of the staff, in accord with the nursing strategic plan.
7. Support staff of one administrative assistant for each director of nursing to manage projects and a staff assistant for each nurse manager to monitor such matters as expense budgets, schedules, and time and attendance.
[Figures 1 to 3 ILLUSTRATION OMITTED]
Several other positions were created to serve the entire division. However, rather than create a separate unit for these division-wide positions, the administrative council allocated these positions among the various directors of nursing. These positions included the research coordinator, education coordinator, work redesign coordinator, central staffing office coordinator, quality and regulatory agency coordinator, and critical care specialty coordinator. Individuals in all of these positions, together with the coordinated care managers and the professional nursing development coordinators, are expected to work with all the teams. The administrative council felt this cross-team approach was important in the reorganization so that staff would think in terms of team building across the DNPS. This same concept was the basis for not clustering units under a director by specialty as in medical-surgical nursing under the old model (see Figure 1). The council tried to keep similar patient populations clustered by director in the new model but also put unlike patient populations together, such as orthopedics and psychiatry.
Once the plan was finished, an all-day workshop for all nursing leadership staff was planned as quickly as possible and held 1 week later. The purpose of the workshop was to explain the relationships between the initial input from staff, the principles derived from the input, and the new model. The initial reaction of the staff who attended the workshop varied. Some leadership staff were angry, feeling the new jobs were impossible; others supported the new model.
The administrative council informed leadership staff attending the workshop about the reconfiguration of 143 jobs in the old model, including 42 jobs that were being eliminated. All staff holding jobs in those 143 positions had to reapply for a job. This process was made somewhat easier since 18 positions were already vacant. However, because of the anxiety created, the council filled the positions as quickly as possible. Everyone at the workshop was given job descriptions for each position and a one page form for applying for jobs. Council members spent as much time as necessary helping staff understand the model and the jobs they were applying for. Individuals had 5 days to submit their application; they were expected to apply for at least three different positions.
During these 5 days, many meetings were held with various groups to communicate the details of the new model. These groups included staff from each nursing unit on various shifts, college of nursing faculty, college of medicine faculty, the hospital management team, and the board of directors, among others. Support was offered to nursing unit groups from a psychosocial clinical nurse specialist and pastoral care personnel to help deal with the changes.
The administrative council met at the end of the 5-day period and determined who would be offered each job. The decisions were made easier by the fact that yearly evaluations had just been completed for all supervisory staff. Human resources agreed that the interview process could be eliminated.
To help the administrative council focus on what was expected from individuals in the new model, one of the directors of nursing developed a Likert scale (see Figure 4) that proved useful. The scale was used to help evaluate individuals in some key performance areas, especially when two individuals applying for the same job seemed to have similar qualifications.
Figure 4. Likert Scale 1-5
1. Collaborative — works with new positions in the organization
2. Change agent — “sell” others on new ways
3. Delegation — ability to let go
5. Engender individual grwoth/empowerment
6. Initiator of change — maintenance no longer acceptable
7. Clear in direction — what they need as a leader; rather than what they need “to do” as a manager
8. Move beyond unti focus — supportive of the entire department/hospital
Positions were offered first to individuals who had been selected for the positions of nurse manager and for the central positions, and they had 5 days to reply. Then the positions of nurse practice coordinator and staff education coordinator were filled. Anyone who didn’t get a position in round 1 was encouraged to apply in round 2. Fifteen people chose to take the reduction in force package. Some of the individuals who took this package took it in conjunction with retirement because it offered a bonus. Others were simply looking for a change. Fortunately, the administrative council placed everyone who was interested in a position and was actually left with a few positions unfilled.
Transition and Transformation Program
Once the model had been announced and the positions filled, a 7-day Transition and Transformation Program was held (see Figure 5). The objectives were:
* Integrate the new model into daily patient care operations.
* Describe the roles in the new model.
* Develop an individual and group work plan to transition to the new model.
* Reach expected outcomes of the work plan by July 1995 (6 months after implementation).
* Commit to three transformational behaviors.
Figure 5. Transition and Transformation Program
“Coming of Age…Growing From Our Past and Present to Create the Future”
Professional Practtice Model Framework
CQI Tools To Use in Building a New Organization
Clinical Resource Management
Health Care Reform
Developing a Professional Practice Team
Collaborattiuon with Medical Staff
Managing the Enterprise
Characteristics of a Team
Tying the Knot: Integrating the Mission, Vision, Past and Future into Managing Change
Evaluation of the Model
Implementing the Model Day VI & VII
“Negotiating at an Uneven Table” [based on her book (Kritek, 1994)]
Once the program was completed, transition to the new roles took place. To mark the end of the old model, the council presented plaques to the leadership staff in the old model, commending them for their contributions to the DNPS. This helped to focus the new leadership group on transition as part of the change process (Bridges, 1991).
As part of the Transition and Transformation Program, the council outlined an evaluation plan for the new nursing organizational model. The new model would be evaluated 6 months after the date all positions in the new model were filled, and then yearly. Three questionnaires were used to evaluate the model. The leadership and nursing staff were given the Index of Work Satisfaction (Stamps & Piedmonte, 1986) and the Group Environment Scale (Moos, 1994). The Multi-Factor Leadership Questionnaire (Bass & Arolio, 1990) was given to the leadership staff only. Responses were obtained from approximately 60% of the new leadership group but only 15% of staff.
In addition to these three questionnaires, the Nursing Unit Cultural Assessment Tool (NUCAT-3) (Coeling, 1993) was also administered within the 6month period. It reflects a more qualitative assessment of each unit’s culture. It was used, for example, to ascertain how the staff felt towards coordinated care as an initiative.
Hospital employees also completed an employee opinion survey during the same 6-month time period. The data were used for additional information about the reorganization.
Overall, the data revealed both positive and negative aspects of the reorganization. The positive, unit-level aspects were higher than average feelings of autonomy, a perception of a unit which promoted innovations, and leadership which inspired people. Opportunities for improvement included nurse-nurse interaction, lack of feeling of effectiveness, decreased satisfaction, and increased anger and aggression, a factor also described by Droppleman and Thomas (1996).
To understand these data better, an outside consultant convened focus groups of the leadership staff in the new model. They were asked to brainstorm, first, the causes of world problems, then causes of national problems, and finally, the causes of Shands’ problems. The group was then asked to identify what they felt were the solutions to Shands’ problems. They identified the causes of Shands’ problems as:
* External controls
These, of course, were a concern because they reflected that staff felt that there were external forces impinging on them and their ability to do work. The administrative council, however, was encouraged that the staff believed that solutions to Shands’ problems could be found internally. These solutions were:
* Group cohesion
* Limits and standards
As members of the administrative council reflected upon the causes and solutions that were presented, they realized that some focus had been lost during the year after the model was implemented. When the reorganization began, the council kept focus on the principles, vision, and strategic plan. But after the model was in place for a while, the council started to lose focus. Some of this was due to the pressure of another $4.1 million cost-cutting target and the rapid and continuous changes in health care. So, the administrative council again looked at the group’s focus and developed principles that had always guided cost management decisions but had not been clearly articulated (see Figure 6).
The key ideas abstracted from these principles were:
* Patient care: Safety and quality outcomes
* Spirit maintenance
* Nursing professionalism
* Patient satisfaction
* Professional autonomy
Figure 6. Cost Management Decision Principles
* Shands Department of Nursing and Patientt Services’ commitment and intentt are focused on patient care, safetty, satisfaction, and quality outcomes; this is the central guideline we honor in cost management decision-making.
* Shands Department of Nursing and Patient Services embraces a model of nursing professionalism which assures autonomy, self-determination, and respect for the human spirit; cost management choices honor these values.
* Shands Department of Nursing and Patient Services believes that cost managementt objectives can only be achieved in a milieu of collaboration and cooperation; cost management initiatives are developed and pursued incorporating the implications of this conviction.
* Shands Department of Nursing and Patient Services believes that honoring these principles is cost effective both in the short and long term; hence, imaginatiuon and creativity are more essential then expedience.
In addition, to reiterate to the staff that the administrative council was committed to maintaining quality while focused on cost management, a commitment to staff was written (see Figure 7) followed by expected commitments from staff (see Figure 8).
Figure 7. Commitmentt to Staff
We, the Shands Department of Nursing and Patient Services, are committed to providing the following to personnel in our division:
* Vision, direction, and leadership.
* Respect for his/her humanity.
* Respect for diversity in the workplace.
* Opportunities to be enriched by diversity.
* A voice of professional nursing in appropriate organizational environment.
* Opportunities for professional development on the job.
* Fair performance appraisal.
* A just salary for services rendered.
* Resources necessary to do his/her job.
* Functional, articulated structures and standards to guide job performance.
Figure 8. Expected Commitments from Staff
We, the Department of Nursing and Patient Services, expect personnel in our division to be personally committed to:
* Responding to vision, direction, and leadership.
* Respecting humanity of all others in the organization.
* Working constructively with the diversity intrinsic to the workplace.
* Responding to opportunities to be enriched by diversity.
* Integrating and supporting the voice of professional nursing in their practice.
* Accessing and integrating professional development opportunities.
* Performing an expected job diligently.
* Rendering services as contracted.
* Accepting consequences for actions taken.
* Managing resources responsibly.
* Performing the job within functional, articulated structures and standards.
These cost management principles and commitments have been distributed to the staff and are being discussed as the DNPS proceeds with cost management. Cost management is a necessary part of administration, but maintenance of quality is as important.
After 1 year, reorganization not only saved $1.2 million of the $4.1 million target but provided additional leadership support to areas that needed it. Adjustments are made in the model as they seem appropriate (the critical care specialty coordinator role was incorporated into the education coordinator’s role). Most impressive, however, is the learning process resulting from a change of this magnitude. Evaluation of the model is ongoing.
SUEELLEN PINKERTON, PhD, RN, is Vice President and Chief Nursing Officer, Department of Nursing and Patient Services, Shands Hospital at the University of Florida, Gainesville.
NOTE: This article is based on a presentation from the 12th Annual Nursing Economic$ Conference, March 9, 1996, Washington, DC.
ACKNOWLEDGMENT: The author wishes to acknowledge the significant contributions of Irene Alexaitis, BSN, RN; Amy Barton, PhD, RN; Joan Blust, MS, RN; Kathleen Cocking, MSN RN; Deborah Ingram, RN, PhD(c); and Rose Rivers, PhD, RN.
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COPYRIGHT 1996 Jannetti Publications, Inc.
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