1. Clarke, Sean P. RN, CRNP, PhD
  2. Carrick, Linda A. RN, CNAA, PhD

Article Content

Once upon a time, frontline nurse managers were expert clinicians familiar with every patient in their units. Looked upon as supervisors, role models, and coaches, they were a major conduit for information on nearly all matters. As financial pressures hit healthcare in the 1980s, however, their role shifted from mainly clinical to heavily managerial. Although nurse managers were still firmly managers of resources and a channel for information in their organizations, by the 1990s, they were also expected to have control over both human resources and clinical issues in our units. Can nurse managers really be expected to be all things to all people?


Today, as nurse manager, you're in charge of a great deal of expensive and scarce resources. Nonetheless, your unit isn't necessarily just a cost center. How well you manage your unit and staff has huge consequences for your institution's revenue stream. Further, everyone in healthcare, executives included, is seeing a spotlight turned on the outcomes that patients experience in healthcare in relation to the enormous money being spent.


Be proactive

Patients, physicians, staff, and workers from other disciplines are increasingly driven by a focus on quality and safety indicators. Providing excellent care is impossible unless you understand expenses and outcomes for each of the services you're imparting. Public image influences how easy it is to recruit staff, and shoring up resources that influence positive outcomes, catching problem numbers, and identifying solutions is more critical than ever. As a result, it's important to be proactive rather than reactive in managing clinical outcomes, defining problems, and identifying and defending necessary resources before a dip in outcomes becomes a real emergency.


One of the best reasons to become outcomes-focused is that tight margins and competing demands are making top-level executives leery of spending money. To ensure your unit gets the resources it needs, have data at your fingertips about the inputs (staffing and other resources) and outputs (processes and outcomes of care) for the major services provided in your unit. Fortunately, you have more data than ever to make your case, as a wide range of financial, stakeholder satisfaction, and clinical outcomes are available.


Get your numbers right

Some of the most pivotal skills for a nurse manager today involve making persuasive arguments defending staffing at levels above or below established figures in his or her unit. You need access to at least three types of numbers: staffing, outcomes, and revenues. Learn what programs or clinical clienteles are the chief income generators in your unit, as these are clinical populations where outcomes should get your top attention. Key numbers to have at your fingertips relate to budget figures, turnover statistics, core measures of clinical performance, outcomes, and patient and physician satisfaction. It's important to see these numbers, preferably with enough data points to give you a sense of trends in order to understand your unit's functioning. And again, you want to understand inputs and outputs before, not after, problems arise.


Two parts to using data persuasively include getting data with which to work, and thinking about and working with it. Depending on your setting, chief nurse officers have cost data, staffing and turnover data, clinical outcome indicators, and possibly revenue data. You may also have performance improvement specialists in your facility who can help you acquire and interpret various kinds of data specific to your unit, as well as a computer-generated dashboard consisting of a cluster of key measures chosen through a consensus process involving the management team of an institution. These key measures would be updated regularly and funneled directly to you and, if need be, nurses and other clinicians providing care in your unit. Institutions that have adopted performance dashboards have accepted that competent management hinges on having access to relevant data in readily understandable forms.


Pay attention

Making intelligent comparisons on outcome measures across units or over time in the same unit is contingent on understanding the definitions and classifications being used. It also means living with inevitable imperfections in data. A number of indicators involve surveys or scrutiny of a sample of records, patients, or healthcare workers. You must understand the sampling strategies being used to correctly interpret differences and changes. In particular, you must be careful about drawing erroneous conclusions from nonrepresentative samples. Especially in the case of satisfaction indicators, be ready to speak up when you see data being interpreted inaccurately.


Last but not least, learn to present data in informative ways to different audiences. It's important that indicators are used to illustrate and communicate points about ways to enhance revenue, improve your market share, and improve clinical outcomes. While statistical analyses can help you identify significant differences and trends over time, simple summary statistics-percentages and averages-will help you tell your story in a professional way. In doing this, it's helpful to show correlations and graphs to tell your story. When you're implementing or expanding a new clinical program, explain the patient care needs and necessary resources to achieve optimal outcomes. Remember that everyone needs at least some background and context before you begin reviewing numbers. Additionally, all audiences appreciate a brief but comprehensive summary of what's been presented, as well as your suggested action plan.


Being a manager involves taking responsibility for finding learning resources to master new skills every year. Increasingly, understanding indicators, how to analyze them, and how to improve them are the subjects of presentations at conferences and articles in practice-oriented nursing administration journals. Since the application process involves detailed analyses on a range of clinical and human resource indicators, Magnet hospitals tend to have a very good handle on analyzing and presenting data on a range of outcomes. Listen to or read their success stories and even reach out for occasional advice.


Adopt leadership skills

Two types of skills are critical for the outcomes-oriented manager. One is using delegation to move away from daily crisis management toward broader strategic and outcomes-focused thinking. Many nurse managers constantly add facets to their roles without moving other work off their plates. Learning and mastering delegation takes time. Build skill sets among your staff members, enabling them to deal with hour-to-hour and day-to-day issues.


The second major people skill involves building coalitions and alliances. Neither learning the skills of using outcomes data in arguments, nor the organizational work required to mount and sustain changes to improve indicators, can be done alone. Form partnerships with others in your organization who have skills complementing yours. If you're particularly expert in clinical care or staff coaching but weak in outcomes and cost/revenue analysis, trade assistance with colleagues who have those strengths. Seek mentoring from colleagues or superiors who are particularly skilled at shaping proposals and business arguments. Lastly, harness data to make important shifts in strategy, drawing on partnerships with other disciplines. Justify new clinical approaches, purchasing decisions, and new policies using outcomes data. Remember that your support network can and should involve physicians admitting patients to your area, financial executives, and workers from other departments as well as nursing.


Achieve clarity through focus

Only recently have healthcare organizations truly embraced the notion that excellence in healthcare must be demonstrated through benchmarking on performance measures. Stakeholders from many different arenas have never been more aware that, once actually measured, outcomes aren't always as positive as they seem. Now that market share and revenues are clearly at stake, remuneration and compensation are increasingly based on performance. More and more performance incentives for managers and executives are based on performance scorecards. These scorecards include several measurements that are consistent with the organizational vision and strategy. For nurse managers, outcomes may include patient satisfaction, staff retention, budget management, and clinical outcome performance.


Taking ownership of your unit as a business and really understanding costs, revenues, consumer demands, and managing strategy to improve performance will be critical to your career in the coming years. Becoming outcomes-focused can give you a compass to find your way through your workday and can also point to logical professional-development opportunities. An outcomes focus will also help you document your growth as a leader over time, which is critical for professional advancement. In the end, clarity about accountability and achievements is beneficial in both the short and long terms for you and your institution. Having been appointed to a managerial position, the skills involved are well within your grasp.