Shoring up nurse supervisors.

They don't teach supervision in nursing school, nor will nurses succeed at it without management's support.

Those of us in nursing home management can easily recite the expense of poor nursing supervision: costly turnover, substandard patient care, low morale, confusion and, inevitably, a poor reputation, both in the community and with regulatory agencies. So what can we do?

One thing that some of us can do for starters is to reconsider our attitudes about nursing supervision. Nursing is a caring profession, and supervision, especially as it incorporates discipline, is felt by many nurses to be counter to the caring persona they believed in when they entered the field. Maybe it's time to reflect on what it takes to deliver the care that nurses feel so strongly about.

Nursing supervision, by the way, covers a broad range of nurses. The Director of Nursing and Assistant DON, Nursing Supervisors, Shift Supervisors, etc., are expected to exercise full supervision as a major part of their jobs. But what of the charge nurse or station nurse who performs treatments, passes medications, orders supplies, updates charts, and is also the supervisor of the nursing assistants or nurses' aides? Are they supervisors who also perform professional tasks, or are they medical professionals who also provide a licensed physical presence in case any questions arise?

Clarification of the supervisory role is paramount.

Sitting in the front row of my class on basic supervision, June stated she had been an RN in a nursing home for three years and had nursing assistants on her station. "I've never really been that clear on where my responsibility or authority starts or ends," she told the class. "I do know I'm in the middle of it when there are problems, but I never feel it's my place to counsel aides on their attitudes, personal improvement or careers."

June's case is typical in many nursing homes. She is told that she is responsible, but her responsibility is not fully clarified, nor is her authority. A policy and procedure manual may lay it out, but in practice can she be sure that she will have the backing of the DON or administrator? Often, nurses are left in a never-never land of uncertainty. The dual demons of this never-never land are lack of clear directives and training, and inconsistent backing of the nurse when she takes decisive action.

Strong, clear directives and consistent backing are exactly what June asked for on her return to her facility from class. In a phone call to me some weeks later, June relayed the success story she had experienced in convincing her DON to "come to the party", i.e., fully empowering her licensed staff to do their jobs. All it took was a re-emphasis on policies already in place (blowing the dust off) and ensuring full management support.

This has both an immediate and a ripple effect. On an immediate basis, nurses feel more comfortable in their roles, and can put full effort into their jobs without concerns of being told they were out of place in taking action. The ripple effects are lower turnover, higher morale and a smoother-running operation. A recent study showed an average cost of one employee turnover at $4,000. For a home with 100 employees and a turnover rate of 25%, this is an annual cost of $100,000. If better supervision could make a major impact by, say, cutting turnover in half, that's a savings of $50,000.

If you don't think this is realistic, review some exit interviews. I have reviewed hundreds, and what I found was that the number-one cause of employees quitting was that they felt that the supervisor "did not treat them right."

Seven Keys to Strengthening Supervision

Putting a program into place to ensure that nursing supervision is the strongest link in your management chain takes commitment and planning. Here are seven keys to making it happen:

1. Respect.

One morning, not long ago, a nursing assistant appeared at my office door in tears, wishing to talk to me. "Dr. Ford, I don't know who to go to, but the nurse out on the station treats me like some kind of animal." We talked it over at great length, going through a half box of Kleenex in the process. It wasn't what the nurse said, and it wasn't what the nurse asked her to do, it was the way she said it. We discussed the possibilities of miscommunication and she thanked me and left. I then had a chat with the nurse involved. She was quite surprised and upset that she was perceived as rude and insensitive. We talked for a while and went through the other half box of Kleenex. After this, I had them both in at the same time, and after each heard the other's side, the problem was resolved. The problem had been the perception of a lack of respect. Perception, in this matter, is just as damaging as the real thing. Make sure all your nursing staff are aware of actions which might be looked upon by others as showing a lack of respect.

2. Role Clarification.

There is that damaging uncertainty, where many nurses don't know where they stand as far as exercising supervision. In words and actions, you must clarify the nurses' supervisory role and support them in it.

3. Communication.

Make every effort to avoid the "rumor mill" or the "grapevine." Numerous short meetings can help. Daily report meetings are good for this - a strong, sincere message can be delivered in 30 seconds. Occasional longer meetings will be needed, perhaps in coordination with inservice training. In whatever length or format, have your nurses take advantage of every opportunity to communicate.

4. Written Policies.

Make sure that written policies are in place and updated regularly. Too often these become outdated, unenforced, and altogether unusable. Nurses need to know what is in their policy manuals and that it is updated and in force. Discussions of this should be held in frequent inservices, and various scenarios covered.

5. Consistency.

Credibility depends largely on the extent to which nurses are supported over the long haul. Therefore, start only those programs and put forth only those policies that you are prepared to support over an extended period of time.

6. Honesty.

Avoid taking the short-term, easy road of making "quick-fix" promises. An example is the nurse who became tired of hearing nursing assistants' concerns about understaffing and stated: "I heard the DON is hiring more staff in a couple of weeks." There was no basis in this hopeful-sounding statement, and it ended up causing considerably more problems than it "solved." Teach nurses to promise only what they can deliver and to always deliver what they promise.

7. Training.

This is the master key to making all the others work. Staff development must include nursing supervision as a major element of its ongoing training program. If supervisory training is perceived only as an unimportant ancillary - a necessity to "fill squares" - it will be ignored for the most part. Emphasize the importance of supervisory training by committing resources to it, and by personally participating and following through.

It is far too easy for management to assume that somehow nurses, as professionals, are fully qualified to supervise, manage and lead people on the job, even if such training has never been provided. Sometimes we're lucky, and get a nurse who is a natural leader and supervisor. Most, though, need training to become that critical part of the management team who takes charge of problems minute-by-minute, 24 hours a day.

John W. found this out several years ago when he took over a nursing home in Colorado that was in decertification. At first glance, the facility seemed to have everything in place: full staff and census, a good-looking building, good equipment and sufficient supplies. The problem? Staff interviews revealed that nurses never dared to challenge a nursing assistant on any procedure, and assistants never asked nurses for advice because they said they didn't trust them. Supervision did not exist, and the residents were in jeopardy. It only took John W. a few weeks of reestablishing lines of authority and supervision to turn around this disaster-in-the-making.

Maybe your situation hasn't gone that far. Perhaps, in fact, you are trying to raise your facility to superstar status. If you focus on the quality of nursing supervision, the benefits will yield far more than the costs involved.

Wayne D. Ford, PhD., is a long-term care consultant based in Hayward, CA and a former president of Welltech National Training Systems.