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Balancing the roles of manager and nurse: duty managers are often the unsung nursing leaders of hospitals. They must be cool headed and multi-skilled, ready to make tough decisions about staffing and bed numbers, and able to step in to assist in a variety of clinical situations.

Being a duty manager combines the best of two worlds, according to tong-time duty manager at Tauranga Hospital, Lynne Nansen. "The clinical component of the rote is strong, but so are the management responsibilities. I love the excitement of the job. Every shift is different--you can never predict what is going to happen."

Hansen has been in the role for the last 22 years, initially taking it on as a favour for a nurse wanting to get off night duty. She soon discovered a real attraction in the rote's leadership component. On afternoon and night shifts, it's the duty manager, not the charge nurse, who is seen as the nurse leader and to whom nurses come for advice or assistance. She also enjoys being able to straddle the two responsibilities of manager and nurse. She believes mental and physical fitness are prerequisites to doing the job welt, as it requires being able to make tough decisions and to step into a variety of clinical situations to assist nurses who are understaffed or under pressure.

Duty managers are fostered on all three shifts at Tauranga Hospital, which has 344 beds and is usually 100-110 percent full. Only one duty manager works each ten-hour shift from a pool of five people. Around 15 years ago, there were two duty managers per shift, but this was reduced to one when more nurses were rostered to the emergency department LED). On the morning shift, the role is primarily one of bed management, but on the afternoon, night and weekend shifts, the role includes bed management, clinical leadership and staff management. Hansen does more night than day shifts and has found that, over the years, her body has adapted well to working at night. "You have to learn to sleep in patches, rather than expecting to steep solidly for eight hours," she says. She enjoys the freedom night shifts give her to play tennis during the week and has even managed to juggle her hours around raising a family and doing her nursing degree. Having only five people available to fill the rote means there is little room to cover for the unexpected like sudden illness. "You just keep going until you drop."

When Hansen arrives at 9.30pm to begin her night shift, the first activity is handover from the afternoon shift duty manager. Then she will do a round of the whole hospital, eyeballing as many patients as she can before the lights are turned out. From then on, she is driven by her locator as new patients are admitted, or she sits in front of her computer looking for staff. "The 'flu season has now hit, so staff are dropping like flies. Fortunately we have a good pool of flexi-staff, but we also have to do a fair bit of begging to get people to come in at short notice. To be an effective duty manager you have to be good at building relationships with staff. They will go the extra mile if you treat them fairly and with respect. Often, of course, we have to move staff to different areas of the hospital and that can cause a lot of tension for some nurses. Your success will depend on how well you can negotiate with people. A bit of praise and humour can go a long way to achieving what you want.

Knowing where the pressure points are

"Sometimes we feet as if we are the meat in the sandwich, trying to balance expectations from management with requests and pleas from staff. Senior management has little understanding of what we do, but we are the ones who understand what's going on and where the pressure points are. First and foremost, however, we are nurses, and you need to be very skilled and confident, able to work in ED one minute, helping with a resuscitation on the ward the next, or assisting a nurse with a heavy workload. Few nurses really understand the tensions in the role. When we introduce new people into it, they are usually amazed at how complex it is and how much responsibility duty managers have. It is actually quite hard to get people to take on the role because not many people like its unpredictability and they often feet unsafe and unsupported. You have to be strong and be able to stick with your decisions."

Hansen believes nurses are now benefiting from the Trendcare Acuity tool which is now used in all areas of Tauranga Hospital. "Nurses were very sceptical about it to start with, but they are now learning to use it in their favour. The key to getting the right result, Like more staff on the ward, is entering the right data."

Hansen has recently been appointed chair of the Clinical Nurse Leaders' Section, NZNO's newest section. The majority of members are duty managers, but members include any nurse leader who is responsible for staff and/or budget.

After hours' manager at Hutt District Health Board (DHB), Diane Maddock, is one of 12 in this rote, covering the afternoon and night shifts. In contrast with Tauranga and other similar sized hospitals, two after hours' managers are rostered on each shift at the 250-bed hospital. "The rote has changed over time and depends very much on the focus of each DHB," she said. "Those with EDs running 24 hours a day or with tertiary responsibilities certainly mean duty managers have a much greater workload. The only patients being transferred to the Hutt Hospital outside the region would be plastics patients being admitted to the intensive care unit (ICU) or onto a ward. We also liaise with other duty managers about transfers of our patients for specialist care we don't provide, eg neurosurgery patients needing to be admitted to Capital and Coast DHB."

Conducting a mini, online census of bed, patient and staff numbers is one of the first tasks Maddock does when she begins her shift. She and her colleague need to know how many staff they have and where they are presently allocated; how many commissioned and available beds there are; and the numbers of potential discharges. "Basically we need to get to grips with what is likely to happen on the night and we need to took ahead to staffing needs over the following three shifts or the coming weekend. We can use nurses from agencies if need be, but, as we have a good pool of casual staff, they get first preference."

Once the mini census has been done, the two duty managers arm themselves with the relevant paperwork and their radio transmitters and head off to do a round of all wards. All after hours' managers have a large clinical component to their roles. This means they need to be ready at any time to roll up their sleeves and do what needs to be done to assist with admissions to ED or ICU, especially burns patients who are nursed in isolation and require up to five people to move them. They see themselves as advocates for patients and will keep an unofficial eye on those whose condition may deteriorate during the shift, or who have been transferred to a ward from ICU.

Like managing an orchestra

"We never exceed our bed numbers on the wards. If need be, we will send people to other services to free up a bed, especially someone who is being discharged the next day. We can also place someone as a "boarder" in another area and then arrange for them to be properly admitted the next day. But the majority of our time is spent looking at staff numbers and skill mix. It's a bit like managing an orchestra. Sometimes we have to deploy staff to other areas, but we try to keep them within their scope of practice or place them with a buddy for support. We have some allocation staff who are senior nurses and prepared to work where they are needed, especially in specialist units, and we try to keep one person free who can step in quickly if things go to custard."

At the end of the first round, the two after hours' managers meet to discuss how the night shift will pan out, prioritising staff and beds according to the greatest needs. Some time later they will do a second round to see whether the plan they have put in place is working.

"After hours' or duty managers are the first point of contact for any complaints. A crisis can range from dealing with blocked toilets or fused lights, to having to call in the pharmacist or deal with someone who has entered the hospital with a gun--not that that happens very often! A death in ED or ICU may mean having to liaise with the police or Coroner's Court and making sure hospital policy is followed.

"We are part of the resuscitation teams, working at the same level as junior medical staff, and we back up our mental health staff, doing a calming and restraint course every six months to keep us up to date. We are also expected to be at a higher level in intravenous therapy than most staff nurses. We are there to ensure all our staff are kept safe. It is not surprising that most duty managers have had experience in ICU."

Maddock believes nurses are ideal to fill duty managers' roles as it is they who know how hospitals and their wards run. They are also able to advise or help out the junior medical staff who are not always aware of wider ward dynamics, thus ensuring good clinical decisions are made. On occasions, they will speak to on-call senior medical staff if their skills are required. Maddock, who is also a delegate for the Lower North Island senior nurses' scoping working party (currently considering senior nurse titles), enjoys the job's unpredictability and the necessity to make on-the-spot decisions. "Things can change quite rapidly and you have to be adaptable. Nurses expect we will step in to help them, but there is also tension to cope with when you start moving staff or patients. Some nurses have little understanding of what's happening in other areas and see only their wards as being busy and under stress. We have to make our own clinical judgements about where staff are most needed and be able to take the Longer-term view. Senior managers are also not always happy with our decisions, but they are not there when we are, so they have to accept what we do. You can't be hung up about being popular in this job, but we try not to be bullies either."

At the end of their shift, the two after hours' managers tie up any loose ends and do their online shift report, noting any problems they have had to deal with over the previous eight and a half hours. Then it's handover to the incoming shift and time to head home, Leaving the hospital comforted by the knowledge they did the best they could with the staff and resources available.
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Author:Manchester, Anne
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:1USA
Date:Jul 1, 2006
Words:1848
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