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Perceptions of first line nurse managers : managing within a climate of fiscal restraint O’Quinn, Mary Claire 1996

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Perceptions of First line Nurse Managers Managing Within A Climate of Fiscal Restraint by Mary Claire O'Quinn B.Sc.N., The University of British Columbia, 1988 A THESIS SUBMITTED IN PARTIAL F U L F I L L M E N T O F THE REQUIREMENTS FOR THE D E G R E E OF M A S T E R OF S C I E N C E IN N U R S I N G in F A C U L T Y OF G R A D U A T E STUDIES T H E S C H O O L OF N U R S I N G  We accept this thesis as conforming to the required standard  T H E UNIVERSITY OF BRITISH C O L U M B I A April, 1996 © Mary Claire O'Quinn, 1996  In  presenting  degree freely  at  this  the  thesis  in  partial  University  of  British Columbia, I agree that the  available for  copying  of  department publication  this or of  reference and study.  thesis by  this  for  his thesis  scholarly  or for  her  of  financial  0^6/  The University of British Columbia Vancouver, Canada  Date  DE-6  (2/88)  of  /M^W  i  the  requirements  I further agree that  purposes  may  representatives.  permission.  Bcpartmcnt  fulfilment  It  gain shall not  be  advanced  Library shall make  by  understood be  an  permission for  granted  is  for  allowed  the  extensive  head  that without  it  of  my  copying  or  my  written  Abstract  The purpose o f t h i s s t u d y was t o examine t h e p e r c e p t i o n s o f f i r s t l i n e nurse managers o f managing w i t h i n a c l i m a t e o f f i s c a l r e s t r a i n t . The l i t e r a t u r e i n d i c a t e s t h a t the f i r s t l i n e nurse manager's r o l e continues to evolve; i t i s increasing i n a c c o u n t a b i l i t y and r e s p o n s i b i l i t y , p a r t i c u l a r l y i n t h e a r e a o f financial responsibility.  As w e l l , f i r s t l i n e  nurse  managers s t r o n g l y i n f l u e n c e t h e q u a l i t y o f c a r e t h a t i s d e l i v e r e d i n Canadian h o s p i t a l s .  They have t h e  r e s p o n s i b i l i t y of ensuring that p a t i e n t s receive high q u a l i t y c a r e d e l i v e r e d i n a c o s t e f f e c t i v e manner. T h i s s t u d y i s p a r t o f a l a r g e r s t u d y by A c o r n and Crawford  (1995) i n which d a t a were c o l l e c t e d through a  s u r v e y completed by 200 f i r s t l i n e nurse managers i n 38 acute c a r e h o s p i t a l s i n B r i t i s h Columbia.  In t h i s  study, a d e s c r i p t i v e e x p l o r a t o r y d e s i g n was used t o examine t h e p e r c e p t i o n s o f nurse managers. groups were conducted  Focus  t o v a l i d a t e t h e d a t a c o l l e c t e d by  the open-ended q u e s t i o n s i n t h e A c o r n and Crawford study, as w e l l as t o f u r t h e r e x p l o r e t h e p e r c e p t i o n s o f f i r s t l i n e nurse managers o f managing w i t h i n a c l i m a t e  of f i s c a l r e s t r a i n t . These d a t a were then  analyzed  u s i n g c o n t e n t a n a l y s i s . Data were f i r s t coded, then organized  under c a t e g o r i e s  from which themes emerged.  The major themes t h a t emerged from t h e d a t a were; e n o r m i t y o f change, impact o f change, and t h e management o f change. The e n o r m i t y o f change r e s u l t e d from h e a l t h care r e f o r m , d e c e n t r a l i z a t i o n o f d e c i s i o n making, i n c r e a s e i n a c c o u n t a b i l i t y and r e s p o n s i b i l i t y of f i r s t l i n e nurse managers, and changes t o t h e d e l i v e r y of p a t i e n t care.  The impact o f change  i n c r e a s e d t h e w o r k l o a d o f f i r s t l i n e nurse managers, c o n t r i b u t e d t o l e s s e f f e c t i v e communication i n t h e f a c i l i t i e s and r e s u l t e d i n u n c e r t a i n t y about t h e i r f u t u r e r o l e i n h e a l t h c a r e . F i r s t l i n e nurse managers used s e v e r a l s t r a t e g i e s t o c o n t r o l c o s t s and o b t a i n t e c h n o l o g i c a l and a d m i n i s t r a t i v e s u p p o r t . In summary, t h e h e a l t h care i n d u s t r y i n Canada i s r a p i d l y changing and i n c r e a s i n g i n c o m p l e x i t y , major c h a l l e n g e s  f o r f i r s t l i n e nurse managers i n  meeting t h e s t a n d a r d s f o r q u a l i t y p a t i e n t The  creating  care.  i m p l i c a t i o n s of the f i n d i n g s f o r a d m i n i s t r a t i v e  nursing p r a c t i c e , nursing education,  nursing  and h o s p i t a l a d m i n i s t r a t o r s a r e p r e s e n t e d .  research,  Table o f C o n t e n t s Page .. . . i i  Abstract Table o f C o n t e n t s  iv  Acknowledgements  vi  Chapter 1: I n t r o d u c t i o n Background Purpose Definitions Significance  ..1 1 3 3 4  ,  Chapter 2: L i t e r a t u r e Review.. H e a l t h Care Reform The Nurse Manager's E v o l v i n g R o l e Summary o f L i t e r a t u r e Review  6 6 11 13  Chapter 3: Methods Research D e s i g n Sample S e l e c t i o n and S e t t i n g Data C o l l e c t i o n P r o c e d u r e s Focus Groups I n t e r v i e w Guide Analysis Rigor E t h i c a l Considerations.. L i m i t a t i o n s and Assumptions  15 15 15 16 17 20 22 24 25 25  Chapter 4: F i n d i n g s Participant Characteristics Themes E n o r m i t y o f Change H e a l t h Care Reform Decentralization A c c o u n t a b i l i t y and C o n t r o l D e l i v e r y o f Care Summary Impact o f Change I n c r e a s e d Workload Communication. Uncertainty Summary  27 27 29 30 32 34 36 40 43 45 46 49 52 58  iv  Management o f Change S t r a t e g i e s t o Manage Change.. Support i n Times o f Change T e c h n o l o g i c a l Support A d m i n i s t r a t i v e Support Summary Chapter Summary  59 59 65 66 68 72 72  Chapter 5: Summary, C o n c l u s i o n s , and I m p l i c a t i o n s . . . . Summary Conclusions Implications Administrative Nursing Practice Nursing Education N u r s i n g Research Hospital Administrators  74 74 79 80 80 81 83 84  References  86  Appendix A - Demographics  91  Appendix B -  Survey Q u e s t i o n s  92  Appendix C - Focus Group I n t e r v i e w Q u e s t i o n s  93  Appendix D - Consent Form  94  v  Acknowledgements  The w r i t i n g o f t h i s t h e s i s has been a c h a l l e n g i n g e x p e r i e n c e , an adventure, and f i n a l l y , a source o f p r i d e . Without the s u p p o r t and encouragement o f my t h e s i s committee,  my f a m i l y , and f r i e n d s i t would  have come t o f r u i t i o n . my t h e s i s committee,  not  For t h a t , I would l i k e t o thank  Dr. S o n i a A c o r n , M a r i l y n Crawford,  and Dr. M a r i l y n D. W i l l m a n . I would l i k e t o g i v e s p e c i a l thanks t o Dr. S o n i a A c o r n f o r her c o u n s e l and f r i e n d s h i p through t h i s p r o c e s s . I would l i k e t o g i v e a v e r y s p e c i a l thanks t o my husband, Tom, Morgan, who  and my c h i l d r e n , B r i t t a n y , J i l l i a n ,  and  are the j o y and i n s p i r a t i o n o f my l i f e .  My  p a r e n t s whose l o v e and encouragement throughout the y e a r s a s s i s t e d me i n b e i n g here today. L a s t l y , I would l i k e t o thank Denise, my f r i e n d and mentor, who w i t h me e v e r y s t e p o f the  way.  vi  walked  1 CHAPTER 1: INTRODUCTION  A c l i m a t e of f i s c a l  restraint,  technological  e x p l o s i o n , and g l o b a l c o m p e t i t i v e n e s s  has  forced  s o c i e t y t o d e a l w i t h unprecedented r a p i d change (Canadian Nurses A s s o c i a t i o n  [CNA], 1993). So s w i f t  u n r e l e n t i n g are the changes t h a t the w o r k p l a c e  and  has  become an environment of chaos where u n c e r t a i n t y i s the norm and change i s the o n l y c o n s t a n t  (CNA).  Background In the h e a l t h c a r e s e c t o r , the changes are known as r e s t r u c t u r i n g and  i n c l u d e d o w n s i z i n g or r e d u c t i o n i n  numbers of employees and h o s p i t a l beds, mergers o r c o n s o l i d a t i o n of h o s p i t a l f a c i l i t i e s ,  and work  redesign  or changes i n p a t i e n t care d e l i v e r y systems (Acorn & Crawford, 1995;  D i c k & Bruce, 1994;  suggests t h a t the p r e s s u r e c a r e system w i l l c o n t i n u e  Roch, 1992).  t o r e s t r u c t u r e the  Roch  health  as governments s t r u g g l e  with  increasing d e f i c i t s . T h i s economic c l i m a t e , which i s the stimulus  f o r r a p i d r e f o r m , has  principal  significant implications  for  the n u r s i n g p r o f e s s i o n .  This i s p a r t i c u l a r l y  true  for  nurse a d m i n i s t r a t o r s whose r e s p o n s i b i l i t y i s t o  2 ensure the d e l i v e r y o f q u a l i t y p a t i e n t c a r e i n the most c o s t e f f e c t i v e manner (CNA,  1988; CNA,  1993; D i c k &  Bruce,  1994; McCloskey, Gardner, Johnson & Mass,  1988).  The r e s p o n s i b i l i t i e s o f nurse  are c h a n g i n g . reducing  administrators  One change i s t h a t o r g a n i z a t i o n s  h i e r a r c h i c a l l e v e l s , thus l e a d i n g t o  are increased  r e s p o n s i b i l i t y and a c c o u n t a b i l i t y a t lower l e v e l s o f management i n the o r g a n i z a t i o n  (Dick & Bruce, 1994).  In n u r s i n g departments, t h i s r e s u l t s i n d e c e n t r a l i z a t i o n o f d e c i s i o n making a u t h o r i t y t o the unit level.  N u r s i n g l e a d e r s advocate t h i s management  s t r a t e g y as a means t o improve m a n a g e r i a l d e c i s i o n s r e s u l t i n g i n b e t t e r q u a l i t y p a t i e n t care while containing costs Copper,  (Dick, & Bruce; Hodges, Knapp, &  1987).  O r g a n i z a t i o n a l changes are c o n t r i b u t i n g t o the e v o l u t i o n o f the f i r s t l i n e nurse manager's r o l e by i n c r e a s i n g i t s scope, r e s p o n s i b i l i t y , a u t h o r i t y , and accountability  ( C a r r o l l & Adams, 1994; Chase,  Eubanks,  1992; F u l l e r t o n , 1993; Mark, 1994).  expanded  role i s being described  as the key  1994; This  nursing  p o s i t i o n i n the h o s p i t a l s e t t i n g w i t h the r o l e incumbent r e s p o n s i b l e  f o r d e c i s i o n s a f f e c t i n g the  3 outcomes, q u a l i t y , and c o s t of p a t i e n t c a r e . d e s c r i b e s t h i s new  Eubanks  nurse manager as the " l i n c h p i n i n  q u a l i t y care and c o s t c o n t r o l " (p. 22). r e p o r t s t h a t nurse e x e c u t i v e s  Eubanks a l s o  c o n s i d e r t h i s the most  c r i t i c a l management r o l e i n h o s p i t a l f a c i l i t i e s . the c l i m a t e o f f i s c a l  Given  r e s t r a i n t and the key p o s i t i o n  t h a t f i r s t l i n e nurse managers are assuming i n the h o s p i t a l , i t would seem t i m e l y t o i d e n t i f y perceptions  of i s s u e s r e l a t e d t o f i s c a l  their  restraint.  Purpose The purpose of t h i s study i s t o e x p l o r e the of f i s c a l  issues  r e s t r a i n t as t h e y r e l a t e t o f i r s t l i n e nurse  managers.  The  perceptions  research question i s :  What are  the  of f i r s t l i n e nurse managers of managing  w i t h i n a c l i m a t e of f i s c a l r e s t r a i n t ? Definitions I n the c o n t e x t of t h i s study the f o l l o w i n g terms are  defined:  1. F i r s t l i n e nurse manager: a nurse r e s p o n s i b l e f o r the 24-hour management of one  or more p a t i e n t u n i t s .  I n d i v i d u a l s i n t h i s p o s i t i o n may  be r e f e r r e d t o as  nurse manager, head n u r s e , and/or u n i t manager.  4  2.  Nurse e x e c u t i v e s :  nurse managers who  represent  n u r s i n g a t the top a d m i n i s t r a t i v e l e v e l . i n d i v i d u a l s are r e s p o n s i b l e  These  f o r the department o f  n u r s i n g and p o s s i b l y o t h e r departments w i t h i n the organization.  Other t i t l e s commonly h e l d by  i n d i v i d u a l s i n c l u d e c h i e f nurse e x e c u t i v e , p r e s i d e n t of p a t i e n t care s e r v i c e s , v i c e  these  vice president,  a s s i s t a n t p r e s i d e n t o f n u r s i n g , d i r e c t o r of p a t i e n t s e r v i c e s , and/or d i r e c t o r of  nursing.  Significance F i r s t l i n e nurse managers are a group t h a t provide  can  i n s i g h t i n t o managing h e a l t h c a r e i n a c l i m a t e  of f i s c a l  restraint.  This study generates  information  on those i n s i g h t s p r o v i d i n g d a t a on the management p r a c t i c e s of n u r s e s .  As w e l l , the s t u d y p r o v i d e s  data  on which f u t u r e s t u d i e s can be based. How  fiscal  r e s t r a i n t a f f e c t s the p r a c t i c e of  l i n e nurse managers may  have i m p l i c a t i o n s f o r  i n n u r s i n g a d m i n i s t r a t i o n and e d u c a t i o n .  Yet,  first  research i t is  the p i v o t a l r o l e of f i r s t l i n e nurse managers i n i n f l u e n c i n g the care o f p a t i e n t s t h a t makes t h i s s t u d y most r e l e v a n t .  A l t h o u g h the r o l e may  i n c r e a s e i n scope, i t w i l l c o n t i n u e  evolve  and  to influence  the  5  care p a t i e n t s r e c e i v e .  Information  on  the p r a c t i c e of  f i r s t l i n e nurse managers w i l l u l t i m a t e l y b e n e f i t p a t i e n t c a r e which i s the aim o f n u r s i n g  knowledge.  a d d i t i o n , t h i s s t u d y w i l l c o n t r i b u t e t o the Canadian r e s e a r c h  limited  on the p r a c t i c e of nurse managers,  p a r t i c u l a r l y i n a c o n t e x t of f i s c a l  restraint.  In  6 CHAPTER 2:  LITERATURE REVIEW  The l i t e r a t u r e r e v i e w c o n s i s t e d o f an e x t e n s i v e computer s e a r c h i n n u r s i n g , n u r s i n g and  hospital  a d m i n i s t r a t i o n , and b u s i n e s s management d a t a bases as w e l l as a manual s e a r c h o f p e r t i n e n t j o u r n a l s . r e s e a r c h was  found on the e f f e c t s o f f i s c a l  w i t h i n health care.  restraint  Fiscal restraint i s a relatively  r e c e n t phenomenon and t h i s may of  No  account  f o r the d e a r t h  r e s e a r c h on the t o p i c , p a r t i c u l a r l y as i t r e l a t e s t o  f i r s t l i n e nurse managers.  T h e r e f o r e , the  literature  r e v i e w f o c u s e d on t o p i c s o f r e l e v a n c e t o the s t u d y : h e a l t h care reform w i t h i n a c l i m a t e of f i s c a l  restraint  and i t s impact on the e v o l v i n g r o l e o f the f i r s t nurse manager.  line  Both a n e c d o t a l l i t e r a t u r e and r e s e a r c h  on t h e s e two t o p i c s are i n c l u d e d .  Literature that  r e p r e s e n t s a Canadian p e r s p e c t i v e i s p r e s e n t e d whenever possible. H e a l t h Care Reform Advocates o f c o n t r o l l i n g h e a l t h c a r e c o s t s over the p a s t two decades were g e n e r a l l y met  with  i n d i f f e r e n c e from p o l i t i c i a n s and b u r e a u c r a t s . Consequently,  r e f o r m d i d not o c c u r .  Instead of  7 developing  efficient  ways of d e l i v e r i n g c a r e ,  i n c r e a s i n g amounts of money were spent on h e a l t h T h i s has  care.  r e s u l t e d i n Canadians h a v i n g the most  e x p e n s i v e p u b l i c l y funded h e a l t h c a r e system i n the world  (Manga, 1992;  1992).  R a c h l i s & Kushner, 1994;  G i v e n t h a t f e d e r a l and p r o v i n c i a l governments  are s t r u g g l i n g to c o n t r o l d e f i c i t s , has  Roch,  h e a l t h care  reform  f i n a l l y become a major focus o f t h e i r a t t e n t i o n  (Manga). Roch (1992) i n d i c a t e s t h a t a d d i t i o n a l h e a l t h e x p e n d i t u r e s w i l l not improve the h e a l t h of Canadians. A l t h o u g h Canada ranks o n l y b e h i n d the U n i t e d S t a t e s i n p e r c e n t a g e o f g r o s s d o m e s t i c p r o d u c t spent on  health  c a r e , i t ranks lower on many h e a l t h i n d i c a t o r s compared to other i n d u s t r i a l i z e d c o u n t r i e s . two  Roch suggests t h a t  f a c t o r s are i n i t i a t i n g h e a l t h c a r e r e f o r m : the  lack  of improvement i n the h e a l t h of Canadians d e s p i t e i n c r e a s e d spending and In h i s a r t i c l e ,  the i n c r e a s i n g n a t i o n a l debt.  Roch (1992) o u t l i n e s r e s t r u c t u r i n g  o b j e c t i v e s o f the h e a l t h care system f o r the  1990s.  These i n c l u d e p a t i e n t h e a l t h s t a t u s outcomes, and e f f e c t i v e n e s s , e f f i c i e n c y , necessity, relevance, economics of the s e r v i c e s p r o v i d e d .  the and  Roch t h e n r e v i e w s  8  the o b j e c t i v e s u s i n g an economic framework w h i c h examines s u p p l y and demand from the p a t i e n t and system levels.  I n summary, Roch l i s t s t e n emerging themes o f  r e s t r u c t u r i n g , a l l o f w h i c h have i m p l i c a t i o n s f o r nursing.  Four o f t h e s e have d i r e c t r e l e v a n c e b o t h t o  n u r s i n g and t o t h i s  study:  .No f u n d i n g o f h o s p i t a l d e f i c i t s .Reductions i n a c u t e c a r e h o s p i t a l beds . C o n t i n u i n g s h i f t s t o ambulatory and community c a r e .More e f f i c i e n t and economic use o f n u r s i n g resources  (p.11)  Roch then l i s t s the f o l l o w i n g i m p l i c a t i o n s f o r n u r s i n g : .Slower growth o f employment o p p o r t u n i t i e s . S h i f t away from acute c a r e h o s p i t a l s t o o u t p a t i e n t c a r e and community c a r e .More a p p r o p r i a t e use o f n u r s i n g s t a f f . I n c r e a s i n g emphasis on management s k i l l s  (p.11)  Roch suggests t h a t w i t h i n change l i e s o p p o r t u n i t y f o r n u r s i n g , p a r t i c u l a r l y i n i n c r e a s i n g the use o f n u r s i n g s k i l l s , management a b i l i t y , and autonomous Opportunity (1992) a r t i c l e .  practice.  f o r n u r s i n g i s the emphasis i n Manga's However, Manga warns the n u r s i n g  p r o f e s s i o n t h a t , h i s t o r i c a l l y , n u r s e s have n o t s e i z e d  (  9 o p p o r t u n i t i e s as t h e y have become a v a i l a b l e . a u t h o r makes r e f e r e n c e occurred, and  The  t o t u r f wars which p r e v i o u s l y  p a r t i c u l a r l y between n u r s e s and p h y s i c i a n s ,  i n d i c a t e s that, with f i s c a l r e s t r a i n t , the t u r f  wars w i l l expand t o i n c l u d e many o t h e r h e a l t h workers.  care  Furthermore, t h e a u t h o r c l a i m s t h a t t h e t u r f  wars a r e b o r n o f two i s s u e s : manpower s u b s t i t u t i o n w i t h cheaper c a t e g o r i e s o f workers and i n c r e a s e i n scope o f s e r v i c e t h a t n u r s e s may p r o v i d e , p a r t i c u l a r l y which n u r s e s can p r o v i d e  services  a t l e s s c o s t than p h y s i c i a n s .  Manga suggests t h e n u r s i n g p r o f e s s i o n may be t h e most q u a l i f i e d and c o s t e f f e c t i v e p r o f e s s i o n t o p r o v i d e c e r t a i n p r i m a r y h e a l t h care s e r v i c e s , b u t t h e r e i s no guarantee t h a t governments o r b u r e a u c r a t s w i l l nurses f o r these s e r v i c e s . a golden o p p o r t u n i t y  utilize  Manga b e l i e v e s n u r s e s have  i n t h e r e f o r m p r o c e s s b u t need t o  be p o l i t i c a l l y a c t i v e t o reshape t h e h e a l t h c a r e  system  t o t h e i r advantage. O'Brien-Pallas suggesting  (1992) echoes Manga's concerns by  t h a t t o i n f l u e n c e h e a l t h p o l i c y , n u r s e s need  to develop p o l i t i c a l s k i l l s . nursing research  O'Brien-Pallas  f o c u s e s on  and t h e need f o r a d d i t i o n a l s t u d i e s on  the c o s t e f f e c t i v e n e s s o f n u r s i n g c a r e , s e r v i c e s , and  10 personnel.  O'Brien-Pallas  argues t h a t , i n o r d e r t o  i n f l u e n c e h e a l t h care reform,  strong e m p i r i c a l evidence  i s needed on t h e c o s t e f f e c t i v e n e s s o f n u r s i n g and t h e s e r v i c e s nurses provide. Dick  (1992) c l a i m s t h a t n u r s i n g a d m i n i s t r a t o r s a r e  making f a r - r e a c h i n g f i n a n c i a l d e c i s i o n s w i t h o u t t h e n e c e s s a r y i n f o r m a t i o n , such as a sound u n d e r s t a n d i n g economics t o make t h e d e c i s i o n s .  of  Dick b e l i e v e s that  nurse a d m i n i s t r a t o r s need i n f o r m a t i o n on t o p i c s such as c o s t - b e n e f i t a n a l y s i s o f nursing care, cost s t a f f mix,  effective  case c o s t i n g i n h o s p i t a l s , and c o s t b e n e f i t s  of managed c a r e and community c a r e , i n o r d e r t o make financial decisions. H e a l t h care r e f o r m  i n t h i s economic c l i m a t e  r e q u i r e s nurse a d m i n i s t r a t o r s t o make d i f f i c u l t financial decisions.  Many o f these d e c i s i o n s  directly  a f f e c t t h e c o s t and t h e q u a l i t y o f p a t i e n t c a r e . H e a l t h care reform,  i n the context of f i s c a l  restraint,  i n f l u e n c e s who i s r e s p o n s i b l e f o r making many o f t h e financial decisions.  W i t h a d e c r e a s e i n management  l e v e l s w i t h i n o r g a n i z a t i o n s and t h e move t o d e c e n t r a l i z i n g d e c i s i o n making t o t h e u n i t l e v e l , many f i n a n c i a l decisions are the r e s p o n s i b i l i t y of f i r s t  11 l i n e nurse managers. The Nurse Manager's E v o l v i n g  Role  Health care reform, d e c e n t r a l i z a t i o n o f d e c i s i o n making, and, e s p e c i a l l y , f i s c a l r e s t r a i n t have contributed  t o s i g n i f i c a n t changes i n t h e f i r s t  nurse manager's r o l e .  line  S p e c i f i c a l l y , t h e scope o f  practice, administrative  r e s p o n s i b i l i t i e s , and f i s c a l  a c c o u n t a b i l i t y o f f i r s t l i n e nurse managers have increased 1994;  ( F u l l e r t o n , 1993; Hodges e t a l . , 1987; Mark,  W e l l s , 1990).  C a r r o l l and Adams (1994) r e v i e w e d  the l i t e r a t u r e from 1982 t o 1992 on t h e work and s e l e c t i o n o f f i r s t l i n e nurse managers. report  These a u t h o r s  t h a t nurse e x e c u t i v e s c o n s i d e r t h e f i r s t  line  nurse manager's r o l e p i v o t a l t o a c h i e v i n g organizational authority,  g o a l s and t h a t t h e r o l e i s i n c r e a s i n g i n  accountability,  and r e s p o n s i b i l i t y .  However, t h e i r f i n d i n g s p r o v i d e l i t t l e e m p i r i c a l  data  about t h i s expanding r o l e and even l e s s about t h e methods f o r s e l e c t i n g f i r s t l i n e nurse managers. C a r r o l l and Adams c l a i m i t i s d i f f i c u l t t o draw c o n c l u s i o n s about t h e work o f f i r s t l i n e nurse managers as t h e s t u d i e s instrumentation,  reviewed d i f f e r e d g r e a t l y i n design, s a m p l i n g t e c h n i q u e , and r e p o r t i n g o f  12  results. In an e a r l i e r s t u d y , Hodges et a l . (1987) a random sample o f 288  surveyed  c h i e f nurse e x e c u t i v e s (CNEs) i n  American h o s p i t a l s on the p r a c t i c e and e d u c a t i o n o f head n u r s e s .  The CNEs were asked t o complete a 3 5 - i t e m  q u e s t i o n n a i r e t o e l i c i t i n f o r m a t i o n on the head n u r s e ' s r o l e , average s a l a r i e s , e d u c a t i o n a l p r e p a r a t i o n , the  e f f e c t i v e n e s s o f c l i n i c a l nurse s p e c i a l i s t s i n head  nurse p o s i t i o n s . who  and  The a u t h o r s found t h a t head n u r s e s  worked i n d e c e n t r a l i z e d a g e n c i e s had more scope  and  r e s p o n s i b i l i t i e s as opposed t o t h e i r c o u n t e r p a r t s i n c e n t r a l i z e d agencies.  The f i n d i n g s a l s o suggested t h a t  head n u r s e s l a c k the f o r m a l e d u c a t i o n needed t o the  demands o f the c u r r e n t r o l e .  CNEs would  fulfil  hire  m a s t e r ' s - p r e p a r e d head n u r s e s i f t h e y were a v a i l a b l e , b e l i e v i n g t h e y were more e f f e c t i v e i n the p o s i t i o n than b a c c a l a u r e a t e - p r e p a r e d n u r s e s and/or c l i n i c a l  nurse  specialists. From a Canadian p e r s p e c t i v e , two r e p o r t s were found r e g a r d i n g the r o l e o f the f i r s t l i n e nurse manager.  B a x t e r (1993) conducted an e x p l o r a t o r y  d e s c r i p t i v e s t u d y t o examine head n u r s e s ' p e r c e p t i o n s of  their roles.  The convenience sample o f 20  head  nurses was  s e l e c t e d from a l a r g e t e r t i a r y c a r e h o s p i t a l  i n B r i t i s h Columbia.  Using Mintzberg's  (1973)  framework f o r d e s c r i b i n g m a n a g e r i a l work, B a x t e r r e p o r t e d t h a t these head nurses p e r c e i v e d themselves managers.  Furthermore,  as  because o f d e c e n t r a l i z a t i o n o f  n u r s i n g departments, head nurses were managing l a r g e r budgets and r e p o r t e d needing a d d i t i o n a l e d u c a t i o n w i t h r e g a r d s t o " d e v e l o p i n g and m o n i t o r i n g manipulating resources w i t h i n f i n a n c i a l  budgets, constraints,  and j u s t i f y i n g r e s o u r c e u t i l i z a t i o n " ( B a x t e r , 1993;  p.  15) . Fullerton's  (1993) a r t i c l e p r o v i d e s an  r e v i e w o f the changing  anecdotal  r o l e and e d u c a t i o n a l p r e p a r a t i o n  o f f i r s t l i n e nurse managers.  In most l a r g e Canadian  h o s p i t a l s , the head nurse p o s i t i o n i s e v o l v i n g t o t h a t o f f i r s t l i n e nurse manager, w i t h i n c r e a s i n g r e s p o n s i b i l i t i e s and  e x c l u s i o n from membership i n a  nurse u n i o n .  F u l l e r t o n acknowledges t h a t no  l i t e r a t u r e was  found t o support t h i s observed  Canada and c o n c l u d e s accounts  s h o u l d be  trend i n  t h a t anecdotal or research forthcoming.  Summary o f L i t e r a t u r e Review In r e v i e w i n g the l i t e r a t u r e , t h e r e i s a n o t a b l e  14 l a c k o f e m p i r i c a l d a t a on h e a l t h c a r e r e f o r m and i t s e f f e c t s on the e v o l v i n g r o l e o f f i r s t l i n e managers. fiscal  Furthermore,  there i s l i t t l e  nurse  r e p o r t e d on  how  r e s t r a i n t w i t h i n h e a l t h c a r e i n f l u e n c e s the  p r a c t i c e o f f i r s t l i n e nurse managers.  However,  s e v e r a l themes emerge from the l i m i t e d r e s e a r c h and anecdotal accounts.  One  i s that h e a l t h care reform i s  o n l y i n the b e g i n n i n g s t a g e s and, t h e r e f o r e , w i l l c o n t i n u e t o have an impact on the way f o r years t o come.  care i s d e l i v e r e d  Second, economic f o r c e s have had a  major impact on the Canadian h e a l t h c a r e system will  c o n t i n u e t o i n f l u e n c e the way  and  care i s d e l i v e r e d .  T h i r d , the f i r s t l i n e nurse manager's e v o l v i n g r o l e been shaped by these f a c t o r s and more.  Because  i s known about the expanded r o l e o f f i r s t l i n e  has  little nurse  managers under h e a l t h c a r e r e f o r m i n the c o n t e x t o f fiscal  r e s t r a i n t , more e x p l o r a t o r y s t u d i e s are needed.  15 CHAPTER 3: METHODS  The d e s i g n , sample and s e t t i n g , d a t a c o l l e c t i o n p r o c e d u r e s , d a t a a n a l y s i s , and e t h i c a l c o n s i d e r a t i o n s are d i s c u s s e d i n t h i s s e c t i o n . L i m i t a t i o n s assumptions  and  o f the s t u d y are a l s o o u t l i n e d . Research  Design  A d e s c r i p t i v e e x p l o r a t o r y d e s i g n was  used t o  examine the p e r c e p t i o n s o f f i r s t l i n e nurse managers managing i n a c l i m a t e o f f i s c a l r e s t r a i n t .  A  d e s c r i p t i v e s t u d y f o c u s e s on a s p e c i f i c event f o r the purpose o f d e s c r i b i n g phenomena r a t h e r than e x p l a i n i n g them ( P o l i t & Hungler,  1995).  E x p l o r a t o r y s t u d i e s are  an e x t e n s i o n o f d e s c r i p t i v e s t u d i e s w i t h the aim o f p r o v i d i n g a r i c h e r u n d e r s t a n d i n g o f phenomena under study  ( P o l i t & Hungler).  This design i s appropriate  when l i t t l e i s known about the t o p i c , as i s the case i n this  study. Sample S e l e c t i o n and  Setting  T h i s s t u d y i s p a r t o f a l a r g e r s t u d y by A c o r n Crawford  (1995) i n which a s u r v e y was  conducted  of  and 200  f i r s t l i n e nurse managers i n 38 acute c a r e h o s p i t a l s throughout  the p r o v i n c e o f B r i t i s h Columbia.  In the  current  study, a p u r p o s e f u l sample o f f i r s t l i n e  nurse  managers from two acute c a r e h o s p i t a l s i n the Lower M a i n l a n d o f B r i t i s h Columbia was interviews.  chosen f o r f o c u s group  Both h o s p i t a l s had p a r t i c i p a t e d i n the  A c o r n and Crawford s u r v e y .  As w e l l , b o t h h o s p i t a l s  p r o v i d e t e r t i a r y c a r e s e r v i c e s t o c i t i z e n s and number between 350 and 550 acute c a r e beds. F i r s t l i n e managers who  nurse  had h e l d t h e i r p o s i t i o n s f o r a t l e a s t  year were asked t o p a r t i c i p a t e i n the i n t e r v i e w s . f i r s t l i n e nurse managers p a r t i c i p a t e d i n one group i n t e r v i e w and seven i n the  one Six  focus  second.  Data C o l l e c t i o n Procedures The c h i e f nurse e x e c u t i v e s o f the two  hospitals  were c o n t a c t e d by one o f the c o - i n v e s t i g a t o r s o f the l a r g e r s t u d y t o o b t a i n agreement f o r s t a f f p a r t i c i p a t i o n i n focus groups conducted by researcher.  this  The c o - i n v e s t i g a t o r o u t l i n e d the t o p i c  under s t u d y and the time commitment i n v o l v e d . Following  t h i s , l o g i s t i c s o f the i n t e r v i e w s were  p l a n n e d by phone by t h i s r e s e a r c h e r .  Confirmation of  d a t e s , p l a c e o f the i n t e r v i e w s , and name and number o f p a r t i c i p a n t s was  obtained.  P r i o r t o each focus group,  p a r t i c i p a n t s were r e q u e s t e d t o complete  a demographic  17 questionnaire age,  (Appendix A)  i n c l u d i n g i n f o r m a t i o n about  e d u c a t i o n a l l e v e l , and  experience.  Focus Groups Focus group i n t e r v i e w s of f i r s t  l i n e nurse  managers were conducted t o : 1) v a l i d a t e the c o l l e c t e d by the open-ended q u e s t i o n s Crawford's  data  i n Acorn  and  (1995) study, and 2) f u r t h e r e x p l o r e  p e r c e p t i o n s of the managers w i t h regards w i t h i n a c l i m a t e of f i s c a l  the  t o managing  restraint.  Focus group i n t e r v i e w s are a q u a l i t a t i v e  data  c o l l e c t i o n t o o l used t o e l i c i t the p e r c e p t i o n s  of  homogeneous groups of i n d i v i d u a l s on a t o p i c o f i n t e r e s t t o the r e s e a r c h e r  (Krueger,  1994).  Focus  group i n t e r v i e w s can be d i s t i n g u i s h e d from o t h e r group processes  (i.e., therapeutic, s e n s i t i v i t y ,  p l a n n i n g , nominal, characteristics  d e l p h i c ) by the p r e s e n c e of s i x  (Krueger).  F i r s t , the group c o n s i s t s  of 6 t o 10 p a r t i c i p a n t s , a l t h o u g h to  12.  to  c o n s i d e r two  advisory,  t h i s may  range from 4  To determine the i d e a l number, i t i s factors.  The  group must be  important small  enough f o r a l l p a r t i c i p a n t s t o be i n v o l v e d and  large  enough t o ensure d i v e r s i t y i n o p i n i o n s . Second, the i n t e r v i e w s s h o u l d be conducted i n a  18 s e r i e s so t h a t i n t e r n a l and  external  assessed f o r t h e i r e f f e c t s . seem to be u n w i l l i n g  For  influences  example, one  to p a r t i c i p a t e .  The  can  be  group  lack  may  of  p a r t i c i p a t i o n may  be because a c r i s i s o c c u r r e d b e f o r e  the  the p a r t i c i p a n t s '  interview  elsewhere. interview  and  I n t e r n a l l y , one  thoughts were  i n d i v i d u a l may  making i t d i f f i c u l t f o r o t h e r s t o s t a t e  o p i n i o n s . I f the  i n t e r v i e w s are  accounted f o r as the l i k e l y to be Third,  i n t e r n a l and  apparent t o the  has  to be  c a u t i o u s not  characteristics members.  study.  For  their  be  influences  researcher. group i s d e t e r m i n e d  However, the  to o v e r l o o k  t h a t may  group may  external  the homogeneity of the  by the purpose of the  the  conducted i n a s e r i e s ,  a p a r t i c u l a r d i f f e r e n t r e s u l t from one  are  dominate  researcher  certain  i n h i b i t disclosure  by  the  example, f a m i l i a r i t y among p a r t i c i p a n t s ,  such as i n work groups, may p a r t i c u l a r l y i f t h e r e are  inhibit any  disclosure,  hierarchical levels  of  power i n those groups. F o u r t h , the purpose of focus groups i s t o the p e r c e p t i o n s of i n d i v i d u a l s consensus or f i n d s o l u t i o n s  elicit  r a t h e r than r e a c h  to problems.  The  fifth  c h a r a c t e r i s t i c i s t h a t these i n t e r v i e w s produce  q u a l i t a t i v e d a t a i n a more n a t u r a l environment than do other data c o l l e c t i o n t o o l s  (individual interviews  open-ended s u r v e y q u e s t i o n s ) . participants  That i s , the  i n f l u e n c e each o t h e r s ' responses j u s t  in real l i f e situations.  or  L a s t , the  as  researcher  p r e d e t e r m i n e s the s u b j e c t of the i n t e r v i e w f o r the purpose o f l e a r n i n g more about a p a r t i c u l a r event, experience,  or t o p i c .  Open-ended q u e s t i o n s ,  logically  sequenced and c a r e f u l l y developed, are used t o the i n f o r m a t i o n which the r e s e a r c h e r The  seeks.  focus group i n t e r v i e w o f f e r s  advantages over i n d i v i d u a l i n t e r v i e w s One,  elicit  several (Krueger, 1994).  the c o s t of c o n d u c t i n g focus groups compared t o  individual interviews i s considerably example, i f one  less.  For  i s t r y i n g t o e l i c i t the p e r c e p t i o n s  of  20 i n d i v i d u a l s , t h i s can be done w i t h t h r e e f o c u s group i n t e r v i e w s compared t o 20 i n d i v i d u a l  interviews.  A n o t h e r advantage i s t h a t a l a r g e amount of  information  can be c o l l e c t e d i n a r e l a t i v e l y s h o r t p e r i o d of time r e s u l t i n g i n quicker r e s u l t s .  T h i r d , the sample s i z e  can be i n c r e a s e d by u s i n g f o c u s groups. research,  In q u a l i t a t i v e  a l a r g e sample i s d e s i r a b l e but not  r e a s o n a b l e due  t o c o s t and time of  individual  always  20 interviews. Another life-like,  advantage i s t h a t , the environment i s more  t h a t i s , p a r t i c i p a n t s respond t o what o t h e r  i n d i v i d u a l s say, which, respond.  i n t u r n , i n f l u e n c e s how  they  T h i s type o f group dynamic o f t e n e n r i c h e s the  d i s c u s s i o n s b r i n g i n g f o r t h i d e a s t h a t o t h e r w i s e might be l e f t u n s a i d .  L a s t , the f o c u s group t e c h n i q u e  r e s u l t s t h a t are e a s i l y u n d e r s t o o d u n l i k e c h a r t s which may  yields  statistical  r e q u i r e a background i n s t a t i s t i c s f o r  interpretation. The  focus group i n t e r v i e w s i n t h i s s t u d y were  conducted by t h i s r e s e a r c h e r who  a l s o a n a l y z e d the  data. I n t e r v i e w Guide The q u e s t i o n s f o r the focus group i n t e r v i e w s are o f t e n r e f e r r e d t o as the i n t e r v i e w guide o r q u e s t i o n i n g r o u t e and are the core t o e f f e c t i v e and s u c c e s s f u l interviews  (Krueger, 1994).  Morgan (1993) suggests  10  t o 12 w e l l - d e v e l o p e d q u e s t i o n s f o r a two-hour i n t e r v i e w as s u f f i c i e n t .  The q u e s t i o n s s h o u l d be  predetermined,  open-ended, and f o l l o w a l o g i c a l , s e q u e n t i a l o r d e r (Krueger, Morgan). The q u e s t i o n s f o r the focus group i n t e r v i e w s i n  21 t h i s s t u d y were d e v e l o p e d u t i l i z i n g the A c o r n and C r a w f o r d literature. questions  t h e f i n d i n g s from  (1995) s t u d y , and from t h e  A c o r n and C r a w f o r d used open-ended  (Appendix B) i n t h e i r s u r v e y i n s t r u m e n t t o  e l i c i t information p e r t a i n i n g to the current climate of fiscal  restraint.  Data from t h e s e open-ended q u e s t i o n s were a n a l y z e d u s i n g c o n t e n t a n a l y s i s t e c h n i q u e s t o i d e n t i f y common themes.  The themes a r i s i n g from t h e d a t a were: F i s c a l  r e s t r a i n t has c r e a t e d many i n t e r n a l and e x t e r n a l p r e s s u r e s on f i r s t l i n e nurse managers; f i r s t  line  nurse managers have l i t t l e i n p u t i n t o t h e making o f d e c i s i o n s that they are expected t o s e l l  to s t a f f ;  f i r s t l i n e nurse managers' workloads have i n c r e a s e d ; c u t b a c k s have a f f e c t e d s t a f f morale and t h e c a r e and s e r v i c e s p r o v i d e d t o p a t i e n t s ; fewer r e s o u r c e s a r e a v a i l a b l e t o meet t h e demands o f i n c r e a s i n g w o r k l o a d s ; and work r e d e s i g n i s b e i n g implemented  t o enable s t a f f  to work more e f f e c t i v e l y w i t h i n l i m i t e d r e s o u r c e s . These themes were then used t o guide t h e development o f the  q u e s t i o n s f o r t h e f o c u s group i n t e r v i e w s  (Appendix  C) . The i n t e r v i e w q u e s t i o n s were d e v e l o p e d by t h e c o -  i n v e s t i g a t o r s o f t h e A c o r n and C r a w f o r d  (1995)  study, a  r e s e a r c h a s s i s t a n t , t h i s r e s e a r c h e r , and a c o n s u l t a n t e x p e r i e n c e d i n f o c u s group methods.  They were t h e n  t e s t e d w i t h a p i l o t group o f s i x f i r s t l i n e  nurse  managers t o e v a l u a t e t h e c l a r i t y i n t h e wording o f t h e q u e s t i o n s , t h e sequencing  o f t h e q u e s t i o n s , and t h e  o m i s s i o n o f any i m p o r t a n t q u e s t i o n s Morgan, 1 9 9 3 ) .  1994;  (Krueger,  The c o n s u l t a n t on f o c u s group  interviews attended the p i l o t to evaluate t h i s i n v e s t i g a t o r ' s a b i l i t y t o f a c i l i t a t e t h e group discussion.  Krueger  suggests i t i s i m p o r t a n t t h a t t h e  moderator d i r e c t t h e p a r t i c i p a n t s ' responses  as t h i s  a f f e c t s the v a l i d i t y of the data. Analysis The f o c u s group i n t e r v i e w s were r e c o r d e d so t h a t t r a n s c r i p t i o n and c o n t e n t a n a l y s i s o f t h e d a t a c o u l d be performed.  The i n t e r v i e w d a t a were t r a n s c r i b e d by a  p r o f e s s i o n a l t r a n s c r i b e r and r e v i e w e d by t h e r e s e a r c h e r t o a s s e s s f o r completeness  and/or e r r o r s i n  transcription. Content  analysis i s a strategy f o r analyzing  r e c o r d e d d a t a i n a s y s t e m a t i c and o b j e c t i v e manner ( P o l i t & Hungler,  1995).  Content  analysis i s a  23 p a r t i c u l a r l y u s e f u l measurement t e c h n i q u e  f o r nursing  r e s e a r c h as i t can be s u c c e s s f u l l y a p p l i e d t o many types o f r e c o r d e d  information.  frequently studied i n nursing  The phenomena (i.e.,  perception,  a t t i t u d e s , needs) can e l i c i t l a r g e volumes o f d a t a p r o v i d e r i c h n e s s and depth about t h e t o p i c under  that  study.  To a v o i d t h e l o s s o f t h e r i c h n e s s and depth o f d a t a , content 1995;  a n a l y s i s i s recommended ( P o l i t & Hungler,  Waltz,  S t r i c k l a n d , & Lenz, 1984).  The p r o c e s s  of content  analysis involves analyzing  the d a t a f o r c a t e g o r i e s which a r e f u r t h e r reduced t o themes.  The c a t e g o r i e s a r e i d e n t i f i e d by codes  (tags  or l a b e l s ) and a r e c l u s t e r e d t o o r g a n i z e t h e d a t a  from  which c o n c l u s i o n s a r e drawn ( M i l e s & Huberman, 1994). The c a t e g o r i e s i n t o which t h e d a t a a r e o r g a n i z e d can be p r e d e t e r m i n e d , t h a t i s , d e r i v e d from t h e t h e o r y  guiding  the r e s e a r c h q u e s t i o n o r from t h e d a t a themselves by c l u s t e r i n g t o i d e n t i f y c a t e g o r i e s as d e s c r i b e d previously.  Waltz,  S t r i c k l a n d , & Lenz (1984) suggest  t h a t b o t h s t r a t e g i e s can be used as l o n g as t h e purpose o f t h e c a t e g o r i z a t i o n i s adhered t o ( i . e . , t h e c a t e g o r i e s l i n k t h e t h e o r e t i c a l background o f t h e i n v e s t i g a t i o n w i t h t h e d a t a and a l s o p r o v i d e t h e b a s i s  from which c o n c l u s i o n s are drawn). A l t h o u g h some o f the r i c h n e s s o f the d a t a can be l o s t through the r e d u c t i o n p r o c e s s , the purpose o f t h i s type o f a n a l y s i s determines  the amount o f  s i m p l i f i c a t i o n not the procedure S t r i c k l a n d , & Lenz,  itself  (Waltz,  1984). Rigor  To ensure r e l i a b i l i t y i n c o n t e n t a n a l y s i s , c o n s i s t e n c y i n i d e n t i f y i n g the u n i t s reliability) categories  both  (unitizing  and c o n s i s t e n c y i n a s s i g n i n g u n i t s t o ( i n t e r p r e t i v e r e l i a b i l i t y ) are  (Waltz, S t r i c k l a n d , & Lenz,  1984).  important  In t h i s  study,  t h e s i s committee members a n a l y z e d a s e c t i o n o f the t r a n s c r i b e d d a t a u s i n g the c o d i n g scheme developed t h i s researcher.  T h i s was  by  t o a s s e s s the degree t o  which they r e c o g n i z e d the codes and t h e i r d e s c r i p t o r s i n the d a t a . T h i s method enhances the r e l i a b i l i t y o f the c o d i n g scheme. The v a l i d i t y i s h i g h l y c o n t e x t dependent and s h o u l d be addressed throughout  the d e s i g n o f the s t u d y .  C o n s i d e r a t i o n s i n c l u d e sample a p p r o p r i a t e t o s u p p l y the d a t a on the t o p i c o f i n t e r e s t , a n a l y s i s methods a p p r o p r i a t e f o r the type o f d a t a c o l l e c t e d ,  and  25 h a n d l i n g o f d a t a executed p r o p e r l y so the a n a l y s i s i s not a d v e r s e l y a f f e c t e d . E t h i c a l Considerations As p r e v i o u s l y s t a t e d , t h i s s t u d y was  conducted  under the a u s p i c e s o f the l a r g e r s t u d y by A c o r n Crawford  (1995) which was  and  approved by the U n i v e r s i t y o f  B r i t i s h Columbia B e h a v i o u r a l S c i e n c e s S c r e e n i n g Committee f o r Research Human S u b j e c t s .  and Other S t u d i e s I n v o l v i n g  The n u r s i n g e x e c u t i v e s o f the  two  h o s p i t a l s chosen f o r the focus groups were g i v e n a copy of the UBC  e t h i c a l approval c e r t i f i c a t e .  The  p a r t i c i p a n t s were r e q u e s t e d t o s i g n a w r i t t e n f o r the taped i n t e r v i e w (Appendix D).  The  consent  consent  o u t l i n e d the purpose o f the study, time commitment, and c o n f i d e n t i a l i t y o f the p a r t i c i p a n t s ' i d e n t i t i e s f a c i l i t i e s i n which t h e y were employed.  and  The r i g h t  to  withdraw from the s t u d y a t any time o r r e f u s a l t o answer any q u e s t i o n s w i t h o u t p e n a l t y t o employment were also outlined. L i m i t a t i o n s and Assumptions A l i m i t a t i o n o f t h i s s t u d y i s t h a t the f i n d i n g s are not g e n e r a l i z a b l e t o o t h e r groups due t o the purposive sampling technique  used.  I t was assumed t h a t f i r s t l i n e nurse managers would d i s c l o s e t h e d e s i r e d i n f o r m a t i o n i n a group s e t t i n g . Furthermore, i t was assumed t h a t t h e f o c u s group i n t e r v i e w format would f a c i l i t a t e among t h e p a r t i c i p a n t s .  discussion  27 CHAPTER 4: FINDINGS  In t h i s c h a p t e r t h e f i n d i n g s from t h e focus group i n t e r v i e w s o f f i r s t l i n e nurse managers a r e p r e s e n t e d and d i s c u s s e d .  The c h a r a c t e r i s t i c s o f t h e p a r t i c i p a n t s  are d e s c r i b e d i n t h e f i r s t s e c t i o n , w i t h  t h e themes  p r e s e n t e d and d i s c u s s e d i n t h e second s e c t i o n .  There  are t h r e e major themes, each w i t h c o r r e s p o n d i n g subthemes: e n o r m i t y o f change, impact o f change, and management o f change. The f i n d i n g s a r e compared t o t h e l i t e r a t u r e where a p p l i c a b l e . Participant  Characteristics  T h i r t e e n f i r s t l i n e nurse managers p a r t i c i p a t e d i n the s t u d y . A l l were female, r a n g i n g i n age from 34 t o 55 y e a r s w i t h a mean age o f 44.  The y e a r s o f  s u p e r v i s o r y e x p e r i e n c e ranged from 3 t o 20, w i t h a mean of  9.5 y e a r s .  Three o f t h e f i r s t l i n e nurse managers  h e l d a diploma i n n u r s i n g , seven h e l d a b a c c a l a u r e a t e degree i n n u r s i n g , and two h e l d b a c c a l a u r e a t e degrees from n o n - n u r s i n g programs. manager h e l d a master's than n u r s i n g .  One f i r s t l i n e  nurse  degree i n a d i s c i p l i n e  other  Two o f t h e b a c c a l a u r e a t e - p r e p a r e d  p a r t i c i p a n t s were w i t h i n a year o f c o m p l e t i n g t h e  28  master's degree i n n u r s i n g . E i g h t of the  13  p a r t i c i p a n t s had completed the q u e s t i o n n a i r e i n the A c o r n and C r a w f o r d (1995)  study.  The p a r t i c i p a n t s shared t h e i r w i l l i n g l y and c o n f i r m e d  experiences  that f i s c a l r e s t r a i n t  h a v i n g a s i g n i f i c a n t impact on p r a c t i c e .  was  The  p a r t i c i p a n t s i n d i c a t e d t h a t t h e i r r o l e has changed over the years and t h a t i t has been dynamic i n n a t u r e . However, f i s c a l r e s t r a i n t has added a new  dimension  t h a t none of them had e x p e r i e n c e d  during t h e i r careers.  One  the impact i n t h i s  of the p a r t i c i p a n t s e x p r e s s e d  way: I t i s v e r y d i f f i c u l t r i g h t now  because we have a  whole g e n e r a t i o n , m y s e l f i n c l u d e d , of n u r s e s  who  have grown up i n a system t h a t anyone c o u l d have a n y t h i n g they wanted. V i r t u a l l y , t h e r e was i n the way  nothing  of p a t i e n t c a r e t h a t c o u l d not  p r o v i d e d . There was  be  not a l o t of t a l k about,  you  know, o f c o s t b e n e f i t , t h a t k i n d of t h i n g l i k e t h e r e i s now  and i t ' s v e r y d i f f i c u l t  f o r people to  take a s t e p back and say w e l l , we cannot have i t l i k e t h a t anymore f o r v e r y good r e a s o n s .  People,  w e l l , the n u r s e s t h a t I work w i t h anyways,  still  have not l e t go o f the way  i t has always been i n  our e n t i r e l i f e t i m e as n u r s e s and l o o k a t new  ways  o f d o i n g t h i n g s because t h a t ' s , we j u s t don't have the background o r the i n s i g h t o r the e d u c a t i o n t o be a b l e t o n e c e s s a r i l y do t h a t and i t i s t e r r i b l y difficult.  I t ' s a mourning, g r i e v i n g l o s s type o f  p r o c e s s t h a t everyone i s g o i n g A l l o f the p a r t i c i p a n t s had budgetary  through. responsibility  f o r t h e i r areas and, t h e r e f o r e , were knowledgeable about the t o p i c o f the study, p r o v i d i n g a p p r o p r i a t e participant input. Themes The  f i n d i n g s i n d i c a t e t h a t the e n o r m i t y o f the  change o c c u r r i n g i n the h e a l t h c a r e s e c t o r i s a major theme. Four c o r r e s p o n d i n g sub-themes, h e a l t h c a r e r e f o r m , d e c e n t r a l i z a t i o n , a c c o u n t a b i l i t y and  control,  and d e l i v e r y o f c a r e , emerged from the d a t a . Impact o f change i s the second theme; i t s sub-themes are i n c r e a s e d workload, communication, and u n c e r t a i n t y o f change. The t h i r d theme i s management o f t h e s e enormous changes. The sub-themes o f s t r a t e g i e s and  support  i d e n t i f i e d b o t h s t r e n g t h s and gaps i n how  first  nurse managers manage these changes.  line  30 E n o r m i t y o f Change In  the f o c u s group i n t e r v i e w s , the f i r s t  line  nurse managers i d e n t i f i e d t h a t change i s and w i l l be a c o n s t a n t f o r h e a l t h c a r e w o r k e r s . They a r t i c u l a t e d t h a t change i n i t s e l f i s not the i s s u e . R a t h e r , i t i s the amount and magnitude o f the change. As one  participant  described: And I t h i n k , you know, we go over h i l l s  and  v a l l e y s don't we? Where our head comes above water  and,  by j o v e , we might even swim a s t r o k e o r two and then t h e r e i s a wave. You know, a month from now we be... But r i g h t now,  r i g h t now,  might  we're h a v i n g a g a l e and  the waves are p r e t t y b i g . Keeping pace w i t h the changes has proven t o be a v e r y complex p r o c e s s .  The f i r s t l i n e nurse managers  i n d i c a t e d t h a t the t r a d i t i o n a l s t r a t e g y p f w o r k i n g  from  a s t r a t e g i c p l a n , i d e n t i f y i n g a necessary course of a c t i o n , and implementing the a c t i o n p l a n s over time l i n e s i s no l o n g e r a f u n c t i o n a l p r o c e s s .  E i t h e r the  s t r a t e g y p l a n i s o u t d a t e d o r the number o f changes r e q u i r e d s i m u l t a n e o u s l y i n the a c t i o n p l a n has made the p l a n n i n g and i m p l e m e n t a t i o n o f time l i n e s i m p o s s i b l e tasks.  31  The  e v a l u a t i o n o f implemented a c t i o n p l a n s  e x i s t e n t , because, b e f o r e  the evaluation process i s  s t a r t e d more changes have been i n t r o d u c e d , the need t o e v a l u a t e plan. and,  i s non-  eliminating  t h e o r i g i n a l change i n t h e a c t i o n  Furthermore, t h e e v a l u a t i o n p r o c e s s i s c o s t l y t h e r e f o r e , i s g i v e n a low p r i o r i t y by h o s p i t a l  a d m i n i s t r a t o r s i n the face o f scarce  resources.  F i r s t l i n e nurse managers i d e n t i f i e d t h e impetus f o r t h e e n o r m i t y o f changes as t h e government h e a l t h care reform which i n c l u d e s , but i s not l i m i t e d t o , decreased funding  t o acute c a r e h o s p i t a l s . T h i s i s  c o n s i s t e n t with the f i n d i n g s i n the l i t e r a t u r e  that  suggest n a t i o n a l debt i s i n i t i a t i n g t h e r a p i d i t y o f h e a l t h care r e f o r m (Roch, 1 9 9 2 ) .  Hospital  a d m i n i s t r a t o r s ' s t r a t e g i e s to deal with funding  cuts  have d r a s t i c a l l y changed t h e way h o s p i t a l s o p e r a t e . D e c e n t r a l i z a t i o n o f d e c i s i o n making t o u n i t l e v e l s and changes i n managers' a u t h o r i t y and a c c o u n t a b i l i t y a r e some o f t h e examples t h a t emerged from t h e d a t a . H o s p i t a l o p e r a t i o n a l changes have a f f e c t e d t h e type o f care and t h e way i n which p a t i e n t care i s d e l i v e r e d . H e a l t h care r e f o r m , b e i n g t h e b r o a d e s t o f t h e changes, i s discussed  first.  32  H e a l t h Care Reform Many i s s u e s arose out o f t h e changes t h a t h e a l t h c a r e r e f o r m imposed.  Support  f o r h e a l t h care reform  was p o s i t i v e among t h e s e f i r s t l i n e nurse managers even though they r a i s e d c o n c e r n s .  One f i r s t l i n e  nurse  manager commented: I am v e r y s u p p o r t i v e o f t h e whole h e a l t h c a r e r e f o r m . There has been e x c e s s i v e waste and abuse of  our system and we have watched i t go on f o r  y e a r s and t h e h e a l t h c a r e r e f o r m i s o n l y coming out o f , out o f a l l t h e f i n a n c i a l problems t h a t were t h e r e and, o t h e r w i s e , we would have never got i n t o h e a l t h c a r e r e f o r m , so h e a l t h c a r e r e f o r m i s good. Another  t a l k e d about t h e f u t u r e :  I can r e a l l y see down t h e road because we a r e t r y i n g {the h e a l t h c a r e system} t o l i n k i n t o t h e community, b r i n g a l l t h e d o l l a r s i n t o one p o t so as a program we're c o n t r o l l i n g t h e d o l l a r s , w i t h o u t s a y i n g , t h a t i s h o s p i t a l d o l l a r s and t h a t ' s community. So I t h i n k t h e outcome f o r p a t i e n t c a r e and f a m i l y c a r e i s g o i n g t o be v e r y p o s i t i v e i f we can do t h a t .  The  f i r s t l i n e nurse managers suggested t h a t  health  c a r e r e f o r m would be b e n e f i c i a l t o p a t i e n t s o n l y i f r e d i s t r i b u t i o n of f u n d i n g was  managed i n a way  to  s u p p o r t the needs o f the p a t i e n t s . For example, i f h o s p i t a l s are b e i n g downsized and c u t t i n g s e r v i c e s , then the s e r v i c e s and the f u n d i n g need t o r e d i s t r i b u t e d t o a g e n c i e s or groups who provide  them at the l e a s t c o s t .  managers had  can  best  These f i r s t l i n e nurse  concerns t h a t h e a l t h care r e f o r m was  u n f o l d i n g the way is,  be  the government has  the d o l l a r s are not b e i n g  not  suggested. That  s h i f t e d t o the community  a l t h o u g h s e r v i c e s are b e i n g c u t .  They a l s o e x p r e s s e d  c o n c e r n t h a t c e r t a i n groups of p a t i e n t s were not r e c e i v i n g the c a r e t h e y needed i n a c u t e care and/or the community because of the f u n d i n g The  cuts i n health  care.  f i r s t l i n e nurse managers b e l i e v e d t h a t h e a l t h  reforms w i l l funding  continue  f o r the f o r e s e e a b l e  future  care  as  i s d e c r e a s e d . T h i s b e l i e f i s echoed i n the  literature,  as Roch (1992) s t a t e s "...the theme f o r  h e a l t h c a r e d u r i n g the 1990s w i l l be one r e s t r u c t u r i n g and  refocussing"  (p. 8).  One  of commonplace  management s t r a t e g y t o b r i n g down c o s t s i n the care i n d u s t r y i s d e c e n t r a l i z a t i o n .  health  Decentralization As h o s p i t a l s r e o r g a n i z e ,  t h e l e v e l s o f management  are b e i n g d e c r e a s e d , w i t h t h e d e c i s i o n making a u t h o r i t y moving downward.  These two changes a r e m u t u a l l y  e x c l u s i v e even though i t would appear t h e y need n o t be. P a r t i c i p a n t s from one f o c u s group n o t e d t h a t o r g a n i z a t i o n had b o t h changes o c c u r r i n g decreasing  their  (i.e.,  management l e v e l s and d e c e n t r a l i z i n g o f  d e c i s i o n making). They r e p o r t e d t h a t t h e a u t h o r i t y f o r certain decisions  ( i . e . , b r i n g i n g s t a f f i n on overtime)  was d e c e n t r a l i z e d t o t h e u n i t l e v e l , b u t , f o r many d e c i s i o n s , i t was u n c l e a r who was r e s p o n s i b l e t o make which d e c i s i o n s .  S e v e r a l i s s u e s arose r e l a t e d t o  d e c e n t r a l i z a t i o n o f d e c i s i o n making. F i r s t , t h e r e were many p o s i t i v e comments s u p p o r t i n g decentralization. quality  of  increased address  First  l i n e nurse managers  the decisions  was  better  f e l t the  and t h a t  a u t h o r i t y i n d e c i s i o n making a l l o w e d issues  more e x p e d i e n t l y .  After  indicated  them t o  reviewing  l i t e r a t u r e on c e n t r a l i z a t i o n o f a u t h o r i t y , W e l l s  the  the  (1990)  t h a t " D e c e n t r a l i z a t i o n i s now synonymous w i t h  e f f e c t i v e n u r s i n g management and h i g h  employee m o r a l e "  (p. 3 ) . Support f o r d e c e n t r a l i z a t i o n was e x p r e s s e d i n  35 t h i s comment: " I t h i n k I s a i d b e f o r e t h e good t h i n g about d e c e n t r a l i z a t i o n ... i s t h e good o p p o r t u n i t i e s we have t o g i v e s t a f f what we want, you know, we don't have t o w a i t any  l o n g e r t o g e t i t passed by so many p e o p l e . " The  f i r s t l i n e nurse managers a l s o i n d i c a t e d t h a t ,  i n most cases, t h e a u t h o r i t y t o make d e c i s i o n s had been passed a l o n g w i t h t h e r e s p o n s i b i l i t y . that  i t would  be  advantageous  a u t h o r i t y c o u l d be d e l e g a t e d  Another expressed  i f decision  making  t o t h e s t a f f nurse  level.  T h i s f i r s t l i n e nurse manager f e l t i t would enable n u r s e s t o f o c u s on managing t h e whole o f p a t i e n t c a r e as opposed t o f o c u s i n g on p a t i e n t c a r e  tasks.  S e v e r a l concerns were r a i s e d by the f i r s t l i n e nurse managers about t h e changes d e c e n t r a l i z a t i o n brought i n t h e i r w o r k p l a c e . For example, f i r s t l i n e nurse managers b e l i e v e d work was b e i n g  "dumped" on them from  various  departments i n t h e h o s p i t a l . I t was suggested t h a t , as responsibility their  authority  increased t o make  d e l e g a t e work t o o t h e r s .  f o r many h o s p i t a l decisions  managers,  allowed  them t o  I t was f u r t h e r suggested t h a t ,  w i t h t h i s new a u t h o r i t y , t h e m a j o r i t y o f t h e t a s k s were b e i n g g i v e n t o f i r s t l i n e nurse managers.  F o r example,  one  how  first  line  nurse  manager  described  another  36  department had the r e s p o n s i b i l i t y t o send i n f o r m a t i o n (a l e t t e r ) t o a l l s t a f f members i n the h o s p i t a l .  A person  i n t h i s department sent the f i r s t l i n e nurse managers the information,  r e q u e s t i n g them t o d i s s e m i n a t e i t t o a l l  s t a f f members. over 100  This f i r s t  l i n e nurse manager, who  s t a f f r e p o r t i n g t o h e r , f e l t t h a t i t was  had  really  not a p p r o p r i a t e f o r her t o spend her time d o i n g t h i s , particularly  when  t h e r e were  other  established  ways  w i t h i n the h o s p i t a l t o d i s s e m i n a t e i n f o r m a t i o n o f t h i s type. In a n o t h e r s i t u a t i o n , the f i r s t l i n e nurse managers d e s c r i b e d how manuals from o t h e r departments were s e n t t o them t o be updated. The  first  l i n e nurse managers were  r e q u i r e d t o i d e n t i f y the n e c e s s a r y changes,  arrange to  have them c o r r e c t e d , and t h e n t o o b t a i n a new These  examples  indicate  that  first  manual.  line  nurse  managers' workloads a r e b e i n g i n c r e a s e d by some o f the changes  resulting  from d e c e n t r a l i z a t i o n .  negative e f f e c t s  outweigh the p o s i t i v e  negative e f f e c t s  of d e c e n t r a l i z a t i o n  Whether the  o r whether  the  are temporary  as  r o l e s a r e c l a r i f i e d i s not known. A c c o u n t a b i l i t y and C o n t r o l The f i r s t l i n e nurse managers i n d i c a t e d t h a t  their  37 a c c o u n t a b i l i t y was c l e a r  ( i . e . , t o c o n t i n u o u s l y improve  the q u a l i t y o f p a t i e n t c a r e and do i t w i t h l e s s money). However,  their  authority  and  a c t i v i t i e s was l e s s e x p l i c i t .  control  over  certain  For example, c o n t r o l over  p a t i e n t admissions or c a n c e l l a t i o n of s u r g e r i e s d i f f e r e d from u n i t  to u n i t .  I f a u n i t was  e x t r e m e l y busy  and  s t a f f i n g was m i n i m a l , c e r t a i n f i r s t l i n e nurse managers could l i m i t  admissions or cancel s u r g e r i e s  b r i n g i n g s t a f f i n on o v e r t i m e pay. has  changed r e c e n t l y  as  one  first  instead  of  However, t h i s p r o c e s s line  nurse  manager  stated: In our p l a c e you know, sometimes you have t o l i m i t the number o f a d m i s s i o n s f o r the day based on your r e s o u r c e s and so f o r t h . much c l e a r e r as t o how  A few months ago,  i t was  that transpired. Right  now,  we're i n a v e r y grey zone and t h a t c r e a t e s a l o t o f problems  f o r a l l the d i s c i p l i n e s as t o are we d o i n g  more c a s e s ? Are we not d o i n g more c a s e s ? There's  a  time element t h a t p e o p l e need t o know by a c e r t a i n hour and t h e r e ' s a l o t o f c o n f u s i o n w i t h i n t h a t and it's  even h a r d  t o know why  that  i s become more  b l u r r e d now then j u s t two o r t h r e e months ago and a l o t o f i t i n t o f i s c a l i t e m s , i s i t okay today t h a t  38  we can use t h e o v e r t i m e b u t y e s t e r d a y i t wasn't? This  example  supports the f i r s t  line  nurse  managers'  s u g g e s t i o n t h a t t h e y have t h e a c c o u n t a b i l i t y f o r managing the  r e s o u r c e s b u t n o t always t h e a u t h o r i t y o r c o n t r o l t o  match  workload  to resources.  The  first  line  nurse  managers i n d i c a t e d t h a t a c c o u n t a b i l i t y w i t h o u t a u t h o r i t y or  control  i s very  frustrating  and undermines  their  c r e d i b i l i t y as i t appears t h e y a r e i n c o n s i s t e n t i n t h e i r management o f matching w o r k l o a d and r e s o u r c e s . A n o t h e r i s s u e d e a l s w i t h t h e communication a s p e c t o f d e c i s i o n making.  I t was e x p r e s s e d by one f i r s t  line  nurse manager t h a t "we a r e so d e c e n t r a l i z e d t h a t we're not connected."  She i n d i c a t e d t h a t w i t h so many changes,  i t was d i f f i c u l t t o keep up w i t h who was r e s p o n s i b l e f o r what.  A l t h o u g h t h i s i n f o r m a t i o n was o f t e n d i s c u s s e d i n  committee  meetings,  the  numerous  changes  d i f f i c u l t t o a t t e n d a l l these meetings. decisions  f o r which  responsible  which  no one seemed added  to  the  made i t  There were many t o know who  feeling  of  being  disconnected. The f i r s t l i n e nurse managers i n d i c a t e d t h a t another a r e a o f d i f f i c u l t y was c o n t r o l l i n g budgets.  staffing  Many f i r s t l i n e nurse managers f e l t t h e y  was  39 needed t o i n c r e a s e t h e i r s t a f f i n g quotas b u t , i n s t e a d , were s t r u g g l i n g w i t h ways t o m a i n t a i n the p r e s e n t levels.  For example,  s t a f f s i c k time has a major  impact on budget because o f the replacement c o s t s f o r absenteeism.  The f i r s t l i n e nurse managers have t o  b a l a n c e the l e v e l s o f s t a f f i n g w i t h the c o s t s o f replacement. I f t h e y r e p l a c e a l l s t a f f who t h e y cannot come i n on budget. I f s t a f f who are  c a l l i n sick are s i c k  not r e p l a c e d , the w o r k l o a d o f those s t a f f who  are  w o r k i n g i n c r e a s e s and f i r s t l i n e nurse managers b e l i e v e d t h i s r e s u l t e d i n even h i g h e r l e v e l s o f absenteeism. The dilemma here i s t h a t many o f the  first  l i n e nurse managers b e l i e v e d t h a t r e s o u r c e s needed t o be i n c r e a s e d i n c e r t a i n areas t o p r e v e n t o v e r r u n s i n t h e i r budgets d u r i n g the y e a r .  However, t h e y d i d not  have the a u t h o r i t y t o move r e s o u r c e s around o r t o spend more money i n ways t h e y b e l i e v e d would e v e n t u a l l y save money.  The l i t e r a t u r e i n d i c a t e s t h a t , i n o r d e r f o r  f i r s t l i n e nurse managers t o be a b l e t o c o n t r o l c o s t s w h i l e i m p r o v i n g the q u a l i t y o f p a t i e n t c a r e , t h e y need to have i n c r e a s e d a u t h o r i t y t o match t h i s responsibility  (Eubanks,  1992).  40  D e l i v e r y of Care S e v e r a l examples were g i v e n by the f i r s t  line  nurse managers about imposed changes t o c a r e d e l i v e r y t h a t were n e c e s s a r y due  t o budget c u t s .  As one  first  l i n e nurse manager e x p r e s s e d : In g e n e r a l ,  I t h i n k p a t i e n t s get b e t t e r c a r e a l l  the time i n s p i t e of s t r e s s t h a t new  technology  and changes i n the department and a l l of these have put on us. Some of the r e s u l t s f o r p a t i e n t s have been p a r t i c u l a r l y good and example, Clinical  paths  I ' l l g i v e you  which were put i n p l a c e  on my u n i t f o r s t r i c t l y f i s c a l r e a s o n s . . . . r e s u l t was t h e r e was  an  b e t t e r c a r e . That was  The  a case where  an improvement i n s e r v i c e .  C l i n i c a l p a t h s are d e f i n e d by Crummer and C a r t e r as f o l l o w s " A c r i t i c a l  pathway d e s c r i b e s  (1993)  a course of  h o s p i t a l i z a t i o n f o r p a t i e n t s w i t h s i m i l a r problems  and  t r e a t m e n t p l a n s . C r i t i c a l pathways are s t a n d a r d i z e d  to  d e s c r i b e the c o u r s e of events t h a t l e a d t o a s u c c e s s f u l p a t i e n t outcome" (p. 3 1 ) .  T h i s f i r s t l i n e nurse manager  i n d i c a t e d t h a t p a t i e n t s were r e c e i v i n g b e t t e r because the outcomes were e x p l i c i t . p r a c t i c e had not o c c u r r e d  care  I f t h i s change i n  f o r t h i s group of p a t i e n t s ,  41  they might have had a p r o l o n g e d  h o s p i t a l course.  Moreover, they might not have r e c e i v e d the i n t e r v e n t i o n s deemed n e c e s s a r y  appropriate  f o r t h e i r problems,  r e s u l t i n g i n a l e s s e r q u a l i t y of c a r e . A n o t h e r example was  g i v e n i n which c l i n i c a l  paths  were used t o s t r e a m l i n e p a t i e n t c a r e throughout hospitalization.  In t h i s p a r t i c u l a r example, the  l e n g t h of s t a y was  b e i n g d e c r e a s e d , the p a t i e n t s were  s p e n d i n g l e s s time i n c r i t i c a l c a r e a r e a s , and i n v a s i v e equipment was  removed from p a t i e n t s sooner.  b e l i e v e d t h a t the l e s s time a p a t i e n t has equipment, the sooner r e c o v e r y b e g i n s , e a r l i e r h o s p i t a l discharge.  It is  invasive  resulting in  Money i s saved by  d e c r e a s i n g the l e n g t h of h o s p i t a l s t a y f o r p a t i e n t s . Furthermore, the c u r r e n t b e l i e f i s t h a t p a t i e n t s r e c o v e r f a s t e r i n t h e i r own  homes which i s b e n e f i c i a l  i n terms of f i s c a l and human c o s t s . In another example, t h i s time i n extended c a r e , the p r a c t i c e was  t o awaken a l l p a t i e n t s (65 t o 75)  at  t e n o ' c l o c k a t n i g h t and two and s i x i n the morning t o change t h e i r i n c o n t i n e n c e d e v i c e s .  F i n d i n g s from a  study conducted a t a n o t h e r f a c i l i t y r e v e a l e d t h a t t h i s p r a c t i c e was  d i s r u p t i v e t o s l e e p and c o s t l y i n terms of  supplies. awakening.  As a r e s u l t , s t a f f o m i t t e d t h e two o ' c l o c k A f i r s t l i n e nurse manager i n t h e c u r r e n t  study i n d i c a t e d that incontinence products the major e x p e n d i t u r e s  were one o f  i n her area. This f i r s t  line  nurse manager adopted t h e p r a c t i c e o f n o t awakening t h e p a t i e n t s a t two o ' c l o c k .  The f i r s t l i n e nurse manager  r e p o r t e d t h a t t h e s a v i n g i n money was s u b s t a n t i a l and, more i m p o r t a n t l y , t h e improvement i n p a t i e n t s ' behaviour,  a f t e r a u n i n t e r r u p t e d n i g h t ' s s l e e p , was  impressive. A n o t h e r f i r s t l i n e nurse manager p r o v i d e d t h e example t h a t i n l a b o u r and d e l i v e r y i t was common p r a c t i c e t o admit p a t i e n t s t o h o s p i t a l who p r e s e n t e d i n f a l s e labour.  That p r a c t i c e has changed i n t h e l a s t  couple o f y e a r s , and p a t i e n t s a r e now r e l e a s e d a f t e r assessment and n o t a d m i t t e d  to hospital.  The f i r s t  l i n e nurse manager r e p o r t e d t h a t t h i s r e s u l t e d i n considerable savings. admissions,  Money was saved because o f fewer  b u t , more i m p o r t a n t l y , p a t i e n t s were b e i n g  subjected to l e s s medical  i n t e r v e n t i o n which i s c o s t  s a v i n g i n b o t h f i s c a l and human terms.  I t was  suggested by more than one f i r s t l i n e nurse manager t h a t f i s c a l r e s t r a i n t was t h e impetus f o r h e a l t h c a r e  43  p r o v i d e r s t o reexamine how c a r e i s b e i n g d e l i v e r e d i n t h e i r a r e a s . The r e s u l t s o f t h e changes i n t h e way c a r e i s p r o v i d e d n o t o n l y showed c o s t s a v i n g s b u t improvement t o t h e c a r e c l i e n t s were r e c e i v i n g o r even better  care,  according t o the f i r s t l i n e  nurse  managers. The changes i n t h e d e l i v e r y o f c a r e were seen as b o t h p o s i t i v e and n e g a t i v e .  The f i r s t l i n e  nurse  managers i n d i c a t e d t h a t some changes r e s u l t e d i n improved p a t i e n t c a r e w h i l e o t h e r s i n d i c a t e d t h a t , a l t h o u g h t h e r e appeared t o be b e n e f i t s , f o r m a l i z e d e v a l u a t i o n s o f changes were n e c e s s a r y b e f o r e making this  assumption.  Summary The  f i n d i n g s i n d i c a t e that the f i r s t l i n e  nurse  managers b e l i e v e d t h a t change was now t h e c o n s t a n t and t h a t change would c o n t i n u e t o be r a p i d and o f g r e a t magnitude. The f i r s t l i n e nurse managers g e n e r a l l y agreed t h a t h e a l t h c a r e r e f o r m was n e c e s s a r y b u t had concerns t h a t p a t i e n t s e r v i c e s might be d i m i n i s h e d i n the p r o c e s s . The concept o f d e c e n t r a l i z a t i o n was s u p p o r t e d i n t h e o r y , b u t had some n e g a t i v e consequences in practice.  However, t h e n e g a t i v e s may be r e s o l v e d as  44 d e c e n t r a l i z a t i o n i s implemented i n t h e i r  respective  facilities. The increase  f i r s t l i n e nurse managers a l s o s u p p o r t e d  the  i n a c c o u n t a b i l i t y but were concerned t h a t  a u t h o r i t y and  c o n t r o l d i d not  always match.  changes i n c a r e d e l i v e r y systems was  the  The  generally  p o s i t i v e , even though the changes were i n i t i a l l y opposed.  The  r e s e a r c h was  f i r s t l i n e nurse managers suggested more n e c e s s a r y to p r o p e r l y  changes o c c u r r i n g  e v a l u a t e some of  the  i n the c a r e d e l i v e r y systems.  However, the t r e n d w i l l  c o n t i n u e as C o l l i n s and  Noble  (1992) w r i t e : Canadian h o s p i t a l s have e n t e r e d an e r a i n which economic c o n s t r a i n t has be,  a dominant f a c t o r i n h e a l t h  This c o n s t r a i n t , and  been, and w i l l  c o n t i n u e to  care d e l i v e r y .  coupled with i n c r e a s i n g  consumer  s t a k e h o l d e r demands, have f o r c e d h o s p i t a l s  r e v i e w s e r i o u s l y the programs t h e y o f f e r and methods of d e l i v e r y . Canadian h o s p i t a l s are downsized, managing w i t h structures  and  their being  organizational  are s t i l l b e i n g asked t o do more  with d e c l i n i n g resources The  leaner  (p.  4).  impact o f these changes f o r f i r s t l i n e nurse  to  45 managers i s g r e a t as t h e f i n d i n g s i n d i c a t e i n t h e following  discussions. Impact o f Change  The demands p l a c e d managers grow d a i l y . administrators,  on t h e f i r s t l i n e nurse  These i n c r e a s e d  demands a r e from  other d i s c i p l i n e s , nursing  s t a f f , and  from p a t i e n t s and t h e i r f a m i l i e s t o do more. l i n e nurse manager d e s c r i b e d  One  first  these demands i n t h i s way:  "On t o p o f s t i l l h a v i n g t o do a v e r y demanding j o b which i s o n l y growing more demanding, because we're a s k i n g p e o p l e t o do more w i t h l e s s and then do i t b e t t e r on t o p o f a l l o f t h a t . " Another s t a t e d : We a r e c o n s t a n t l y i n a p o s i t i o n o f j u s t i f y i n g our existence,  we a r e w o r k i n g w i t h s t a f f who work v e r y  hard, a r e e x p e c t e d t o do a v e r y comprehensive r o l e but  as [she] s a i d , I t h i n k do i t f a s t e r and  cheaper and more, more o f i t r i g h t now and t h a t i s a real  challenge.  S t i l l another s t a t e d : The problem i s t h a t t h e h o s p i t a l i s t r y i n g t o do,  t o do a g r e a t many changes w i t h o u t n e c e s s a r i l y  h a v i n g t h e f i s c a l b a c k i n g t o do i t , and i t ' s s o r t  46 of two t h i n g s g o i n g on a t t h e same t i m e . I mean I f i n d i t extremely d i f f i c u l t  to deal with that,  we a r e d e a l i n g w i t h t h e f o u r o r f i v e and s i x changes g o i n g on a t t h e same t i m e . The f i r s t l i n e nurse managers d e s c r i b e d t h e impact o f the changes as an e x t r e m e l y d i f f i c u l t  challenge to  meet, p a r t i c u l a r l y because t h e c o m p l e x i t y o f t h e c h a l l e n g e s grew d a i l y . One sub-theme o f t h e impact o f change t h a t emerged from t h e d a t a as a r e s u l t o f t h e demands was t h e i n c r e a s e i n t h e f i r s t l i n e nurse manager's w o r k l o a d . The changes a f f e c t e d t h e communication w i t h i n the f a c i l i t i e s ,  structures  a f a c t which t h e y b e l i e v e d had a  major impact on t h e i r w o r k l o a d . Communication i s s u e s arose as a second sub-theme o f t h e impact o f change. U n d e r l y i n g t h e concerns around w o r k l o a d and communication  was t h e t h i r d sub-theme, u n c e r t a i n t y .  R e g a r d l e s s o f how much commitment and e f f o r t t h e y p u t i n t o t h e i r j o b s t h e f i r s t l i n e nurse managers b e l i e v e d t h a t t h e environment Increased  o f u n c e r t a i n t y was ever p r e s e n t .  Workload  The d a t a from t h e f i r s t l i n e nurse managers' focus group i n t e r v i e w s c l e a r l y i n d i c a t e d t h a t t h e y b e l i e v e d  47  t h a t t h e i r workloads were i n c r e a s i n g .  W i t h t h e changes  i n o r g a n i z a t i o n a l s t r u c t u r e s r e s u l t i n g i n fewer m a n a g e r i a l p o s i t i o n s , the f i r s t l i n e nurse managers f e l t t h e y , more t h a n o t h e r s , were increased workloads. this.  experiencing  There were s e v e r a l reasons f o r  For example, t h e f i r s t l i n e nurse managers  r e p o r t e d t h a t work n o r m a l l y departments  c a r r i e d out by o t h e r  i s now b e i n g d e l e g a t e d  t o them.  Departments a r e i n t r o d u c i n g new programs and d e l e g a t i n g the i m p l e m e n t a t i o n and f o l l o w up o f t h e s e programs on the u n i t s t o f i r s t l i n e nurse managers. One f i r s t  line  nurse manager d e s c r i b e d how she was asked t o do y e t another  job.  When she e x p l a i n e d  t o t h e p e r s o n how busy  her s c h e d u l e was the response was " I am not a s k i n g you f o r 100% o f your e f f o r t ,  I am o n l y a s k i n g 1 0 % . "  f i r s t l i n e nurse manager e x p l a i n e d ,  As t h e  " I f you put 10%  i n t o t h a t and 10% i n t o the 12 o t h e r p r o j e c t s t h a t you have you have 120% and you do not have a good j o b o f anything."  The f i r s t l i n e nurse managers  explained  t h a t t h e s e p r o j e c t s were i n a d d i t i o n t o t h e i r w o r k l o a d , which was a l r e a d y  normal  demanding.  S e v e r a l f i r s t l i n e n u r s e managers commented t h a t s t a f f s u p p o r t needs have i n c r e a s e d d r a m a t i c a l l y as  48  s t a f f t r y t o cope w i t h the changes. time has i n c r e a s e d , increased,  For example,  the number o f g r i e v a n c e s  sick  has  and i s s u e s t h a t are not u s u a l l y o f concern  have become a f o c u s .  Two  o f the f i r s t l i n e nurse  managers from d i f f e r e n t h o s p i t a l s i n d i c a t e d t h e y were spending the m a j o r i t y o f t h e i r time frustrated staff.  supporting  They suggested t h a t imposed h o s p i t a l  changes have c r e a t e d an environment  i n which t h e y spent  most o f t h e i r day " f i g h t i n g f i r e s and p i c k i n g up the p i e c e s . " As one f i r s t l i n e nurse manager s t a t e d "...because  the s i c k time i s way up, the o v e r t i m e i s  up, i t ' s r i d i c u l o u s and who has t o d e a l w i t h i t , we have t o . " The p u b l i c i s a l s o p l a c i n g i n c r e a s i n g demands on the h e a l t h c a r e system.  P a t i e n t s and t h e i r f a m i l i e s  are more i n v o l v e d i n t h e i r c a r e , more knowledgable about h e a l t h c a r e , and concerned t h a t the changes w i l l have n e g a t i v e  consequences  f o r them.  The f i r s t  line  nurse managers suggested t h a t i t i s the p u b l i c ' s perception  t h a t t h e y are l o s i n g something w i t h the  changes and some c l i e n t s respond by demanding s e r v i c e s t h a t were never a v a i l a b l e t o b e g i n w i t h .  The  l i n e nurse managers a l s o i n d i c a t e d t h a t t h e s e  first  49 m i s c o n c e p t i o n s were i n p a r t due  t o the l a c k o f  e f f e c t i v e communication. Communication i s the second sub-theme of the impact of change and i s d i s c u s s e d next. Communication Communication i s a b r o a d term g e n e r a l l y used t o denote i n f o r m a t i o n exchange (Mish, 1983). In the context of t h i s d i s c u s s i o n , i t r e l a t e s to issues of i n f o r m a t i o n exchange f o r f i r s t l i n e , nurse managers i n a changing environment.  Many i s s u e s were r a i s e d i n the  focus group d i s c u s s i o n s about the need f o r e f f e c t i v e communication, t h a t i s , the n e c e s s a r y i n f o r m a t i o n  being  g i v e n t o the a p p r o p r i a t e p e r s o n at the r i g h t t i m e .  In  a study by Chase (1994),  b o t h the knowledge of  and  a b i l i t y t o c a r r y out e f f e c t i v e communication was  seen  as the most s i g n i f i c a n t s k i l l n e c e s s a r y f o r f i r s t  line  nurse managers. I t was  suggested t h a t as the amount and magnitude  of change i n c r e a s e d , communication became l e s s effective.  Furthermore, the f i r s t l i n e nurse managers  suggested t h e r e was and t h a t i t was  f a r too much i n f o r m a t i o n exchanged  a major waste o f t i m e .  l i n e nurse manager s t a t e d :  As one  first  50 The  l e f t arm  sometimes doesn't know what the  arm  i s d o i n g and we  right  can have i n s e r v i c e s and  s e v e r a l booked at the same time. . . we have so manyforms o f communication, I don't know how  the  staff  can p o s s i b l y keep up. The  f i r s t l i n e nurse managers i n d i c a t e d t h a t t h e r e  was  c o n f u s i o n w i t h the amount o f i n f o r m a t i o n t o be disseminated. As a n o t h e r s t a t e d : How  many d i f f e r e n t b u l l e t i n s and  f l y e r s e t c . are  coming out and we've got computers and we've got v o i c e m a i l . . . s u d d e n l y anyone has the a u t h o r i t y t o l e a v e me messages on my  v o i c e m a i l , p l u s send a  b u l l e t i n , a s p e c i a l b u l l e t i n , and t h e n put i t i n the r e g u l a r b u l l e t i n t h a t goes around. T h i s statement r e v e a l e d t h a t the d i s s e m i n a t i o n i n f o r m a t i o n was  very disorganized, there  information overload,  of  was  and the n e c e s s a r y i n f o r m a t i o n  was  not r e a c h i n g the a p p r o p r i a t e p e o p l e i n a t i m e l y manner. A n o t h e r f i r s t l i n e nurse manager c l a i m e d t h a t m a i l was  p i l e d t a b l e h i g h and t h a t i t was  almost  impossible to deal w i t h a l l t h i s i n f o r m a t i o n . was  the  a l s o d i s c u s s i o n about i n f o r m a t i o n b e i n g  There  announced  51 b e f o r e the p e o p l e most l i k e l y i n f o r m a t i o n were c o n s u l t e d .  t o be a f f e c t e d by  the  For example, i t was  announced i n a g e n e r a l h o s p i t a l m e e t i n g t h a t a u n i t c l o s i n g as of a c e r t a i n d a t e .  The  f i r s t l i n e nurse  manager r e s p o n s i b l e f o r t h i s area was  unaware of t h i s  c l o s u r e , and the impact of t h i s news was the s t a f f .  The  devastating to  f i r s t l i n e nurse manager was  awkward p o s i t i o n of h a v i n g t o t r y and support members w h i l e d e a l i n g w i t h her own  was  put i n the staff  feelings in this  situation. The  communication i s s u e s are v e r y complex. As more  changes o c c u r , the need t o communicate e f f e c t i v e l y i s heightened.  However, w i t h so much i n f o r m a t i o n b e i n g  disseminated, effective.  communication a c t u a l l y became l e s s  T h i s g r e a t l y a f f e c t e d the f i r s t l i n e nurse  managers as i t became i n c r e a s i n g l y d i f f i c u l t  to provide  the a p p r o p r i a t e i n f o r m a t i o n i n a t i m e l y manner.  This  gave r a i s e t o s p e c u l a t i o n and rumours which seemed t o h e i g h t e n the u n c e r t a i n t y t h a t f i r s t l i n e nurse managers and s t a f f were e x p e r i e n c i n g .  U n c e r t a i n t y i s the  sub-theme of the impact of change and w i l l be next.  third  discussed  52 Uncertainty F e e l i n g s o f u n c e r t a i n t y may be e x p e r i e n c e d  during  t i m e s o f change and t h i s was t h e case w i t h t h e s e participants.  The u n c e r t a i n t y was s t r o n g l y e x p r e s s e d  w i t h r e g a r d s t o t h e f u t u r e o f t h e f i r s t l i n e nurse managers' r o l e , t h e i r j o b s e c u r i t y , and t h e e f f e c t s t h a t changes i n t h e f i r s t l i n e nurse manager's r o l e would have on p r o f e s s i o n a l n u r s i n g p r a c t i c e as w e l l as on p a t i e n t c a r e .  D u r i n g d i s c u s s i o n s o f these i s s u e s ,  emotions, such as f r u s t r a t i o n , anger, and p o w e r l e s s n e s s , were v e r b a l i s e d . The  u n c e r t a i n f u t u r e o f t h e p a r t i c i p a n t s ' r o l e was  e x p r e s s e d by one i n d i v i d u a l i n t h i s way: As  f a r as t h e head nurse p o s i t i o n i s concerned, I  don't t h i n k e i t h e r o f us wake up any day knowing whether o r n o t we're g o i n g t o have a j o b i n a week from now. There's complete u n c e r t a i n t y w i t h i n a l l of o u r j o b s , and t h a t i n i t s e l f i s something t h a t we haven't e x p e r i e n c e d b e f o r e , experienced The  I haven't  before.  f i r s t l i n e nurse managers e x p r e s s e d how t h i s  u n c e r t a i n t y had a major impact on t h e d a i l y l e v e l o f s t r e s s t h e y were e x p e r i e n c i n g .  As one s t a t e d :  53 So c e r t a i n l y a g r e e i n g  with everything  everyone has  s a i d about t h e i s s u e s i n terms o f s t r e s s o r s on us, c o n t i n u i n g e d u c a t i o n ,  job uncertainty,  i n c r e a s i n g r e s p o n s i b i l i t y and t h e need t o always j u s t i f y e x i s t e n c e and say why s h o u l d j o b o r why s h o u l d t h i s j o b e x i s t .  I have t h i s  I t i s very  s t r e s s f u l and f e e l i n g such l a c k o f c o n t r o l i n o u r environment t h a t we j u s t k i n d o f , which way a r e we b e i n g pushed now o r p u l l e d now and I t h i n k t h a t c a r r i e s down t o t h e s t a f f as w e l l . The f i r s t l i n e n u r s e managers v e r b a l i z e d p o w e r l e s s n e s s over f u t u r e u n c e r t a i n t y r e g a r d i n g  j o b l o s s as one  stated: And I t h i n k we ought t o r e l a t e t o what's i n the s o c i e t y i n general,  happening  you know we're s i n g i n g  the same song t h a t everyone i s i n t h e c o r p o r a t e setting i s singing.  You know, we've got t h a t  fear outside at l e a s t .  You've got a j o b so don't  make waves. Another s t a t e d : So d i r e c t l y how i t [ f i s c a l r e s t r a i n t ] impacts on me, i s t h a t t h e r e ' s now an element o f u n c e r t a i n t y w i t h i n t h e head nurse r o l e . I p e r c e i v e  54 t h a t they are c u t t i n g back and changing the s t a n d a r d r o l e and a l s o the d i f f e r e n t The  f i r s t l i n e nurse managers e x p r e s s e d  titles.  frustration  not  o n l y w i t h the i n c r e a s i n g r e s p o n s i b i l i t y but a l s o w i t h the e x p e c t a t i o n s o f a d m i n i s t r a t o r s f o r a d d i t i o n a l educational preparation.  In o r d e r f o r f i r s t l i n e nurse  managers t o keep pace w i t h the added r e s p o n s i b i l i t y , they i n d i c a t e d t h e r e was necessary  p r e s s u r e t o o b t a i n the  e d u c a t i o n u s i n g t h e i r own  resources.  I t was  f e l t by i n d i v i d u a l s t h a t t h e r e were no rewards or i n c e n t i v e s i n p l a c e f o r f i r s t l i n e nurse managers t o advance t h e i r e d u c a t i o n .  With f i s c a l  restraint,  monetary rewards were not f o r t h c o m i n g but most d i s t r e s s i n g was  the f a c t t h a t t h e r e would most l i k e l y  not be a j o b f o r them t o r e t u r n t o i f you took the  time  and money t o advance t h e i r l e v e l o f e d u c a t i o n . However, the f i r s t l i n e nurse managers i n d i c a t e d t h a t most o f them were i n s c h o o l as w e l l as managing f u l l - t i m e j o b s . They suggested l a y o f f s , and,  t h a t w i t h a l l the changes t h e r e would be therefore, competition for l i m i t e d  p o s i t i o n s . The h i g h e r the e d u c a t i o n l e v e l  they  o b t a i n e d , the b e t t e r p o s i t i o n e d they would be t o s u c c e s s f u l l y compete t o keep t h e i r j o b s .  55 The l i t e r a t u r e s u p p o r t s t h i s t r e n d t o h i r e m a s t e r ' s - p r e p a r e d nurses as managers (Hodges, Knapp, & Cooper, 1987; Mark, 1994). One r e a s o n t h a t m a s t e r ' s p r e p a r e d n u r s e s were d e s i r a b l e was f o r t h e i r a b i l i t y t o think c r i t i c a l l y .  Henry (1992), i n a s t u d y o f 97  community h o s p i t a l f i r s t l i n e nurse managers and 110 m e t r o p o l i t a n t e a c h i n g h o s p i t a l f i r s t l i n e nurse managers found, "For c r i t i c a l was a s i g n i f i c a n t  thinking a b i l i t y there  (p<.05) main e f f e c t o f e d u c a t i o n w i t h  m a s t e r ' s - p r e p a r e d managers s c o r i n g s i g n i f i c a n t l y h i g h e r (p<.05) than e i t h e r t h e b a c c a l a u r e a t e o r diploma a s s o c i a t e degree groups"  (p. 7 4 ) . Mark compared d a t a  c o l l e c t e d from a 1992 s u r v e y o f c h i e f n u r s i n g executives i n V i r g i n i a with several other reports. F i n d i n g s i n d i c a t e d t h a t c h i e f nurse e x e c u t i v e s (CNEs), p a r t i c u l a r l y CNEs from l a r g e r h o s p i t a l s  (>300 b e d s ) ,  were more w i l l i n g t o h i r e m a s t e r ' s - p r e p a r e d n u r s e s . Other p a r t i c i p a n t s e x p r e s s e d f r u s t r a t i o n over whether t h e r e would always be n u r s e s i n t h e f i r s t nurse manager r o l e . One p a r t i c i p a n t  line  stated:  We a r e i n t h e t h r o e s , as o f May, o f g o i n g i n t o program management. We have a team l e a d e r who i s a s o c i a l worker and t h e r e o r i g i n a l l y was not t o be  56  a head nurse by December w i t h i n program management and we're s t i l l  i n the t h r o e s o f d e c i d i n g  t h e r e w i l l be a head nurse and w i l l be p a r t - t i m e nursing  whether  that p o s i t i o n  and what the f u n c t i o n s w i l l be from a  perspective.  Anger and f r u s t r a t i o n were e x p r e s s e d over the p o s s i b l e impact o f not h a v i n g n u r s e s i n f i r s t l i n e nurse manager p o s i t i o n s and how t h a t would i n f l u e n c e p r o f e s s i o n a l nursing p r a c t i c e . One  f i r s t l i n e nurse manager, who was w o r k i n g i n a  program management s t r u c t u r e , b e l i e v e d t h e r e were not any i n f r a s t r u c t u r e s i n p l a c e f o r s t a f f n u r s e s t o discuss practice issues. nurse i s r e s p o n s i b l e  She i n d i c a t e d t h a t the head  f o r e n s u r i n g p r a c t i c e s t a n d a r d s on  the u n i t s and i m p l e m e n t i n g changes i n p r a c t i c e f o r nurses.  The head nurse a l s o a s s e s s e s the impact o f  p r a c t i c e changes which i n c l u d e s e n s u r i n g  that p o l i c i e s  and p r o c e d u r e s are e s t a b l i s h e d , and t h a t s t a f f n u r s e s have the e d u c a t i o n  and s k i l l s ,  as w e l l as the knowledge  of t h e i r r e s p o n s i b i l i t y , w i t h r e g a r d t o the change i n practice. T h i s f i r s t l i n e nurse manager b e l i e v e d t h a t n u r s e s s h o u l d be r e s p o n s i b l e  f o r t h e i r own  staff  professional  57 practice.  However, w i t h o u t t h e f i r s t l i n e nurse  manager, t h e l i a i s o n between s t a f f n u r s e s and i n p u t i n t o changes t h a t a f f e c t t h e i r p r a c t i c e may be l o s t . Moreover,  t h e f i r s t l i n e nurse managers r e p o r t e d t h a t  o r g a n i z a t i o n a l s t r u c t u r e s were n o t i n p l a c e f o r s t a f f nurses t o provide the necessary input.  This d i s c u s s i o n  r a i s e d concerns t h a t n u r s i n g would n o t be r e p r e s e n t e d w i t h i n t h e program management s t r u c t u r e w i t h o u t t h e head nurse p o s i t i o n . The l o g i s t i c s o f e n s u r i n g t h a t s t a f f  nurses  r e p r e s e n t n u r s i n g i n meetings w i t h i n program management s t r u c t u r e s needs t o be d e v e l o p e d . I t was suggested t h a t n u r s e s ' s c h e d u l e s a r e n o t f l e x i b l e enough t o a l l o w a n u r s e w i t h p a t i e n t assignments t o a t t e n d meetings.  The  f i r s t l i n e nurse managers d i d n o t b e l i e v e t h i s was a l o g i s t i c a l problem w i t h o t h e r d i s c i p l i n e s , the  flexibility  as t h e y have  t o s c h e d u l e t h e i r work around m e e t i n g s .  The c o n c e r n was t h a t n u r s i n g has been c h a l l e n g e d w i t h p r o v i d i n g 24-hour coverage.  Providing nursing input at  meetings, which g e n e r a l l y o c c u r between t h e hours o f 8am and 4pm, would prove t o be v e r y d i f f i c u l t . Another c o n c e r n r a i s e d by t h e f i r s t l i n e nurse managers was t h a t , i f f i r s t l i n e nurse managers were  58 non-nurses, p a t i e n t care would be compromised.  This  was i m p l i e d by t h e f i r s t l i n e nurse managers because t h e y b e l i e v e , t h a t n u r s i n g as a p r o f e s s i o n was u n d e r v a l u e d (by s e n i o r a d m i n i s t r a t o r s )  even though i t  was n u r s e s who were t h e b e s t advocates f o r p a t i e n t s . Because n u r s i n g was u n d e r v a l u e d , f i r s t l i n e nurse managers c o u l d be r e p l a c e d by n o n - n u r s i n g managers whose f o c u s was c o s t e f f e c t i v e n e s s r a t h e r t h a n q u a l i t y patient  care.  Summary The  impact on t h e f i r s t l i n e nurse managers'  p r a c t i c e from t h e changes i n h e a l t h c a r e d r i v e n by t h e f i s c a l environment was s i g n i f i c a n t a c c o r d i n g  to the  f i n d i n g s from t h e f o c u s group i n t e r v i e w d a t a .  Although  t h e r e were many i s s u e s r e l a t e d t o i n c r e a s i n g w o r k l o a d s , the s t r e s s o f t h e w o r k i n g environment, l a c k o f e f f e c t i v e communication, and t h e s t r e s s o f p o t e n t i a l j o b l o s s , t h e f i r s t l i n e nurse managers'  greatest  c o n c e r n was t h a t o f t h e p r o f e s s i o n a l p r a c t i c e environment and i t s e v e n t u a l  impact on p a t i e n t  care.  They b e l i e v e d i f n u r s i n g l o s t i t s advocacy r o l e f o r p a t i e n t care s t a n d a r d s ,  which c u r r e n t l y i s l i n k e d t o  the f i r s t l i n e nurse manager's r o l e (Sovie,  1994),  59  p a t i e n t c a r e would s u f f e r . The  t h i r d theme i s the management of change.  This  theme t o g e t h e r w i t h the sub-themes, s t r a t e g i e s t o manage change and  support i n t i m e s o f change  ( t e c h n o l o g i c a l and  a d m i n i s t r a t i v e ) , are d i s c u s s e d  in  the f o l l o w i n g s e c t i o n . Management of Change I t was  evident  t h a t change had  from the focus group  discussions  an impact on a l l a s p e c t s of the  l i n e nurse manager's r o l e .  The  complexity  magnitude of the changes p r o v i d e d  rich  and  discussions  about the s t r a t e g i e s used t o manage changes. discussions  on managing r e s o u r c e s and  needed ( t e c h n o l o g i c a l and challenges  was  first  the  administrative)  Moreover,  support t o meet the  discussed.  S t r a t e g i e s To Manage Change The  f i r s t l i n e nurse managers gave s e v e r a l  examples of how  t h e y managed the changes t h a t  from s h r i n k i n g budgets and  resulted  i n c r e a s i n g workloads.  F i r s t , b e f o r e f i r s t l i n e nurse managers can e f f e c t i v e l y manage t h e s e changes t h e y must be aware respective patient populations  and  of t h e i r  f i n a n c i a l data.  The  l i t e r a t u r e i n d i c a t e d that cost e f f e c t i v e q u a l i t y care  60  can be r e a l i z e d by f i r s t l i n e nurse managers (Eubanks, 1992; Mark, 1994; S o v i e , 1994). S o v i e suggests t h a t a master's  degree i n b u s i n e s s i s no l o n g e r a s u i t a b l e  a l t e r n a t i v e because o f t h e c r i t i c a l r o l e t h a t n u r s e s p l a y i n a c h i e v i n g q u a l i t y c a r e and d e s i r e d p a t i e n t outcomes.  S o v i e has suggested t h a t graduate  level  education i n nursing i s r e q u i r e d f o r the p o s i t i o n of f i r s t l i n e nurse manager as w e l l as s u f f i c i e n t  theory  i n b u s i n e s s management t e c h n i q u e s . One o f t h e f i r s t l i n e nurse managers e x p r e s s e d t h e importance  o f knowledge about f i n a n c i a l  data i n t h i s  way: One o f t h e t h i n g s I t h i n k a l l o f us have been d o i n g i s r e a l l y l o o k i n g a t our d a t a n o t o n l y i n terms o f l e n g t h o f s t a y and p a t i e n t d a t a b u t a l l our f i n a n c i a l  d a t a and r e a l l y l o o k i n g a t where  we a r e spending o u r money and how we a r e spending our money. So t h a t ' s s o r t o f , even b e f o r e we develop any s o r t o f s t r a t e g i e s t o d e a l w i t h i t . And so we get t h e r e p o r t s now we need t o be a b l e to j u s t i f y where we a r e spending i t . Once t h i s awareness was e v i d e n t t o f i r s t l i n e  nurse  managers, s t r a t e g i e s were developed t o r a i s e t h e  61 awareness o f s t a f f , p h y s i c i a n s , and s t u d e n t s about the c o s t o f s u p p l i e s and d i a g n o s t i c t e s t s .  As one  first  l i n e nurse manager e x p r e s s e d : We have the s t a f f v e r y i n v o l v e d i n t h a t t h e y have gone around and put up the c o s t o f t h i n g s and  they  are l o o k i n g a t the budget s h e e t s and t h e y are measuring  them from month t o month t o l o o k and  see  i f t h e y have made a d i f f e r e n c e and the house s t a f f the same t h i n g .  We o r i e n t the house s t a f f  time t h e y come t h r o u g h the door and uh,  every  the  equipment t h e y use, the s u p p l i e s , the Swans Ganz c a t h e t e r which c o s t s $206.00. Another  f i r s t l i n e nurse manager found t h a t l a b e l l i n g  items w i t h the p r i c e was v e r y b e n e f i c i a l  in raising  s t a f f awareness o f c o s t . T h i s r e s u l t e d i n s t a f f making s u g g e s t i o n s on how L i n e n was mentioned  t o reduce usage o f e x p e n s i v e i t e m s . by s e v e r a l o f f i r s t l i n e nurse  managers as b e i n g a v e r y e x p e n s i v e s u p p l y i t e m .  The  l a u n d r y c o s t s per p i e c e o f l i n e n are charged t o the units.  When the managers and the s t a f f became aware o f  t h i s , s e v e r a l s t r a t e g i e s were i n t r o d u c e d : u s i n g the same b l a n k e t s e v e r a l times b e f o r e p u t t i n g i t i n the l a u n d r y , o r d e c r e a s i n g the number o f f l a n n e l s  used  62 (more e x p e n s i v e than f l a t s h e e t s ) , and not changing bed sheets on a d a i l y b a s i s u n l e s s i t was  the  necessary.  Once these s t r a t e g i e s were i n p l a c e , l a u n d r y c o s t s were drastically  reduced.  The f i r s t l i n e nurse managers i d e n t i f i e d  that  awareness and e d u c a t i o n o f s t a f f were n e c e s s a r y t o f a c i l i t a t e the change t h a t c o s t e f f e c t i v e n e s s i s everyone's  f i s c a l r e s p o n s i b i l i t y . Once t h i s  concept  ( t h a t everyone has a r o l e i n f i s c a l r e s p o n s i b i l i t y ) was a c c e p t e d by s t a f f and p h y s i c i a n s , changes o c c u r r e d i n c l i n i c a l p r a c t i c e that r e f l e c t e d cost e f f e c t i v e practices.  For example, p r a c t i c e s t h a t were c a r r i e d  out on a r o u t i n e b a s i s were s c r u t i n i z e d . f i r s t l i n e nurse managers d e s c r i b e d how  One  this  o f the concept  h e l p e d s t a f f examine r o u t i n e s t h a t l e d t o change i n p r a c t i c e . She  stated:  That i s the k i n d o f f u t u r e t h a t I see i s l o o k i n g at what i t i s we are d o i n g f o r p e o p l e i n s t e a d o f c a r t e b l a n c h e , d o i n g e v e r y t h i n g f o r everybody, r e a l l y j u s t i f y i n g why  i t i s t h a t someone s h o u l d  get i t and someone e l s e does not get i t o r whatever,  and t h a t w i l l u l t i m a t e l y r e s u l t i n some  c o s t containment  as w e l l I would t h i n k .  63 The f i r s t l i n e nurse managers d e s c r i b e d how  practices  were changed t h a t were b o t h b e n e f i c i a l i n c o s t s a v i n g s and p a t i e n t c a r e .  For example, one u n i t examined the  r o u t i n e b l o o d work s c h e d u l e d and found a c o s t s a v i n g i n d e c r e a s i n g the number o f the b l o o d t e s t s b e i n g done. They changed t h i s r o u t i n e by d e c r e a s i n g r o u t i n e bloodwork and a l l o t h e r t e s t s were done o n l y i f n e c e s s i t a t e d by the p a t i e n t ' s c o n d i t i o n .  This  i n d i v i d u a l i z e d o r c u s t o m i z e d c a r e b e n e f i t e d p a t i e n t s by r e d u c i n g the number o f u n n e c e s s a r y and u n c o m f o r t a b l e p r o c e d u r e s w i t h o u t compromising p a t i e n t c a r e . Furthermore; i t saved the h o s p i t a l money and d e c r e a s e d s t a f f ' s workload.  One  f i r s t l i n e nurse manager  v a l i d a t e d t h i s o c c u r r e n c e w i t h t h i s statement: We have a l s o , from a p a t i e n t p e r s p e c t i v e , had a c o n s i d e r a b l e s a v i n g s over the l a s t c o u p l e o f y e a r s i n p a t i e n t s t a y and j u s t i n l a b o u r i n t h a t p e o p l e coming i n e a r l y l a b o u r o r f a l s e l a b o u r , un, are now  sent home, s e n t home on pass r a t h e r than  hanging onto them f o r hours on end when t h e y a r e not i n e s t a b l i s h e d l a b o u r and t h a t has  actually  saved a whole l o t o f money i n i n t e r v e n t i o n s as well.  Harder t o prove but i t appears t h a t our  64 cesarean  s e c t i o n r e d u c t i o n r a t e s go down when we  practice that. A n o t h e r area i n which s t r a t e g i e s were employed t o save money was replacement o f s t a f f on s i c k c a l l s and holidays.  Although  t h e r e were u n i o n c o n s t r a i n t s w i t h  regards t o s t a f f schedules,  t h e r e were s a v i n g s when n o t  a l l s t a f f who c a l l e d i n s i c k were r e p l a c e d , which has been t h e u s u a l p r a c t i c e .  The s t r a t e g y i n v o l v e d  e d u c a t i n g t h e s t a f f about a s s e s s i n g t h e a c t u a l on t h e u n i t and d e t e r m i n i n g  workload  i f they needed a 12-hour  replacement o r someone f o r o n l y a p o r t i o n o f t h e s h i f t . The s t a f f were d e l e g a t e d t h e t a s k o f replacement o f s t a f f when f i r s t l i n e n u r s e managers were u n a v a i l a b l e . A n o t h e r s t r a t e g y was t o o f f e r s t a f f members l e a v e s o f absence o r v a c a t i o n s p a r t i c u l a r l y d u r i n g  slower  p e r i o d s which o c c u r d u r i n g summer and/or t h e C h r i s t m a s season.  There were s u b s t a n t i a l s a v i n g s when s t a f f were  on p a i d h o l i d a y s , b u t d i d n o t have t o be r e p l a c e d . Although  t h e r e were many e x c e l l e n t examples g i v e n where  s t r a t e g i e s produced s a v i n g s o r promoted c o s t e f f e c t i v e n e s s , t h e f i r s t l i n e nurse managers i n d i c a t e d t h e r e were r e s o u r c e s  s t i l l b e i n g wasted. Examples were  g i v e n o f h o s p i t a l - w i d e programs t h a t were i n i t i a t e d  65  which had care.  a d i r e c t impact on the c o s t o f d e l i v e r i n g  I t was  suggested t h a t t h e r e were many h i d d e n  c o s t s t h a t u n i t budgets had  t o absorb i n o r d e r f o r the  i n i t i a t i v e s t o be a s u c c e s s . t h a t t h e r e was  I t was  a l s o suggested  a l a c k o f , or i n a p p r o p r i a t e ,  impact  a n a l y s i s done b e f o r e c e r t a i n changes were implemented which r e s u l t e d i n wasted r e s o u r c e s . have been w i t h h e l d  S p e c i f i c examples  to respect c o n f i d e n t i a l i t y .  A n o t h e r s t r a t e g y i n d i c a t e d by these f i r s t nurse managers was  t o d e v e l o p o r enhance the  structures within t h e i r f a c i l i t i e s . change w i l l be d i s c u s s e d  line  support  Support i n times of  next.  Support In Times of Change Two  categories  t e c h n o l o g i c a l and  of s u p p o r t emerged from the  administrative.  The  data:  f i r s t l i n e nurse  managers suggested t h a t the need f o r t e c h n o l o g i c a l a d m i n i s t r a t i v e support increased occurred.  and  as more changes  In o r d e r t o manage the changes, the  first  l i n e nurse managers b e l i e v e d t h e y needed d a t a t o them d i r e c t i o n i n t h e i r d e c i s i o n making.  One  give  first  l i n e nurse manager s t a t e d : We  have a problem i n t h a t we  equipment t h a t i s c u r r e n t . We  do not have need the  technology  66 of today.  We  do not have i t .  We  need i t t o  o r i g i n a t e you know prompt d e c i s i o n s t h a t are based on sound d a t a .  We  do not have t h a t d a t a .  We  cannot get i t f a s t enough because the systems are not i n p l a c e . The  f i r s t l i n e nurse managers i n d i c a t e d t h a t access t o  p a t i e n t d a t a was did  l i m i t e d . For example, t h e i r  facility  not have the t e c h n o l o g y t o generate r e p o r t s  they  needed, o r t o support f i n a n c i a l d e c i s i o n s t h a t needed t o be made.  There was  general  agreement among a l l the  f i r s t l i n e nurse managers t h a t t e c h n o l o g i c a l s u p p o r t was  lacking. Technological  t h e r e was  Support.  As p r e v i o u s l y mentioned,  r i c h d i s c u s s i o n among the f i r s t l i n e nurse  managers i n the focus group i n t e r v i e w s about the growing w o r k l o a d and One  i n c r e a s i n g demands p l a c e d on them.  f r u s t r a t i n g a s p e c t about the i n c r e a s e d demands  was  the l a c k of c l e r i c a l and t e c h n i c a l s u p p o r t t o a s s i s t them i n c o p i n g w i t h t h e s e changes. nurse managers were r e s p o n s i b l e  These f i r s t  f o r the s u p e r v i s i o n  20 t o 70 f u l l - t i m e e q u i v a l e n t p o s i t i o n s  of  (individual  s t a f f numbers are g r e a t e r as many p o s i t i o n s are by p a r t - t i m e  line  filled  workers) and managed budgets from $800,000  67 to $3.3 m i l l i o n A c o r n , 1995,  (Acorn & Crawford, 1995;  i n press).  Crawford &  The m a j o r i t y o f f i r s t  line  nurse managers r e p o r t e d t h e y had no s e c r e t a r i a l  support  w h i l e a few r e p o r t e d t h a t t h e y had v e r y l i m i t e d access t o such s u p p o r t .  I n d i s c u s s i n g t h i s i s s u e , one  first  l i n e nurse manager s t a t e d : The o t h e r t h i n g I t h i n k t o o t h a t , t o me, i t ' s a gender i s s u e because I don't know o f any o t h e r manager t h a t has t h e r e s p o n s i b i l i t y t h a t we have and  i t becomes more and more and more; we have no  secretarial  help.  The f i r s t l i n e nurse managers f e l t t h e r e was a l a c k o f respect  from s e n i o r a d m i n i s t r a t o r s because t h e y were  not p r o v i d e d w i t h s e r v i c e s t h a t managers (mostly males) i n t h e p r i v a t e s e c t o r would s i m p l y not work  without.  A l t h o u g h t h e f i r s t l i n e nurse managers acknowledged there i s a cost attached  to providing  secretarial  s e r v i c e s , t h e y suggested t h a t i f t h e y were n o n - n u r s i n g managers w i t h e q u i v a l e n t provided  r e s p o n s i b i l i t y , t h e y would be  with this service.  The essence here i s t h e enormous  responsibility  t h e s e f i r s t l i n e nurse managers a r e c o p i n g w i t h o u t even t h e b a s i c m a n a g e r i a l s u p p o r t s .  with, In another  68 quote, a f i r s t l i n e nurse manager s t a t e d " t h e r e are a w f u l l o t more t h i n g s we we had  an  c o u l d do more e f f i c i e n t l y i f  the t e c h n o l o g y a v a i l a b l e t o us. I mean you  guys  would p r o b a b l y be a b l e t o cope a b i t b e t t e r w i t h a s e c r e t a r y r i g h t now...". d i s c u s s i o n centered were l a c k i n g .  The  t e c h n o l o g y support  on o f f i c e i n f o r m a t i o n systems t h a t  A l t h o u g h most had  access t o  personal  computers, the programs were l i m i t e d , and/or the p r i n t e r s were shared, and one  had  t o walk t o a n o t h e r  f l o o r or b u i l d i n g t o p i c k up the p r i n t e d work. mentioned t h a t E - m a i l and modems would be A d m i n i s t r a t i v e Support.  The  It  was  helpful.  f i r s t l i n e nurse  managers v e r b a l i z e d the l a c k of s u p p o r t from s e n i o r management i n terms of p r o j e c t s b e i n g w i t h o u t the r e s o u r c e s  implemented  needed t o c a r r y them out.  s i t u a t i o n would c h a l l e n g e  the f i r s t l i n e nurse managers  t o have s t a f f a c c e p t p r o j e c t s when i t was the e d u c a t i o n a l I t was  or f i s c a l r e s o u r c e s  e x p r e s s e d by one  This  evident  that  were not a v a i l a b l e .  f i r s t l i n e nurse manager t h i s  way: Two  t h i n g s I see i s t h a t i n s i t u a t i o n s l i k e  we  j u s t spoke about t h a t the management need t o s u p p o r t the s e n i o r management and  s u p p o r t us  and  69 t h e y are a s k i n g us and we are t a l k i n g money a b i t , but t h e y are a s k i n g us t o be f i s c a l l y r e s p o n s i b l e and we,  I t h i n k a l l o f us are and i f we make our  d e c i s i o n , i f t h e y say maybe i t ' s not the b e s t d e c i s i o n but t h a t ' s the b e s t d e c i s i o n you c o u l d make at t h i s t i m e . The next time l o o k a t t h i s , but the support i s not t h e r e and I do not expect our directors  t o be around a l l the time because t h e y  have a l o t o f work as w e l l , but i t would be n i c e i f we c o u l d see them now  and a g a i n o r even t h e y  c o u l d j u s t come by whatever,  but b a s i c a l l y  just  support people. The f i r s t l i n e nurse managers were not  feeling  s u p p o r t e d but d i d not want t o p l a c e blame.  The  d i s c u s s i o n s about the l a c k o f s u p p o r t were q u a l i f i e d w i t h comments about how I t was  d i f f i c u l t i t was  f o r everyone.  a l s o suggested t h a t s e n i o r management would  not always support f i r s t l i n e nurse managers on i s s u e s t h a t arose between p h y s i c i a n s and f i r s t l i n e nurse managers.  For example, t h i s s c e n a r i o was d e s c r i b e d :  W e l l , i t ' s i n t e r e s t i n g because I , I was  t r y i n g to  s e t my p r i o r i t i e s and, and I thought you know, I was d o i n g an OK j o b and so I , you know, I have  70 an a s s i s t a n t head nurse and so t h e y are r u n n i n g the  day-to-day o p e r a t i o n s and I was t r y i n g  i n t o my o f f i c e  t o get  t o o r g a n i z e a l l o f the d i f f e r e n t  d e c e n t r a l i z a t i o n t h i n g s and the groups and t h e n you know, the hew kind of s t u f f .  computer system and a l l t h a t  The p h y s i c i a n s complained t o the  d i r e c t o r t h e y d i d not see me, t h a t was said  and so, you know,  f i n e . So we had t h i s d i s c u s s i o n and I  OK.  T h i s f i r s t l i n e nurse manager b e l i e v e d she was  changing  her p r a c t i c e t o meet the demands o f change, and when the  d i r e c t o r spoke t o her about the p h y s i c i a n s '  concerns she d i d not f e e l s u p p o r t e d .  There were  d i s c u s s i o n s r e g a r d i n g the l a c k o f s u p p o r t from s e n i o r management i n terms o f r e s p e c t f o r f i r s t l i n e nurse managers and n u r s i n g s t a f f . F i r s t l i n e nurse managers emphasized  the need f o r  f i r s t l i n e nurse managers t o s u p p o r t each o t h e r . A l t h o u g h t h e y wanted s u p p o r t from s e n i o r management, i t was  suggested t h a t t h i s was out o f t h e i r c o n t r o l  t h a t r e a l s u p p o r t c o u l d come from each o t h e r . f i r s t l i n e nurse manager p h r a s e d i t t h i s  and  One  way:  R e a l l y , i n t h e s e t i m e s , I t h i n k we r e a l l y need t o  71 s u p p o r t each o t h e r w i t h the d i f f i c u l t i e s we a l l e n c o u n t e r i n g and, before, you  yesterday  or the  someone made a comment t o me  are  day  that, w e l l ,  know, some head n u r s e s r e a l l y have as heavy a  w o r k l o a d as o t h e r head n u r s e s and  I thought, w e l l ,  i f n u r s i n g i s g e t t i n g i n t o t h a t k i n d of a, how I, how  do  can I measure what her w o r k l o a d i s ? I mean  i t i s not f o r me  t o judge and uh,  a l l our  roles  are v e r y d i f f e r e n t i n the d i f f e r e n t areas and lot  of d i f f e r e n t i s s u e s i n terms of  whether t h e y ' r e but  a  staffing,  j u n i o r s t a f f , s e n i o r s t a f f , anyway  i t j u s t s t r u c k me  that i f w i t h i n nursing  we  are s t a r t i n g t o fragment l i k e t h a t . The  f i r s t l i n e nurse managers e x p r e s s e d concern t h a t  some f i r s t l i n e nurse managers were s t a r t i n g t o judge each o t h e r ' s w o r k l o a d and  t h i s was  creating divisions  w i t h i n the n u r s i n g r a n k s .  T h i s had  the p o t e n t i a l f o r  devastating  e f f e c t s and what was  s u p p o r t from each o t h e r , not  r e a l l y needed  was  criticism.  Through the d i s c u s s i o n s , comments suggested t h a t s u p p o r t needs had changes and  i t was  i n c r e a s e d as a d i r e c t r e s u l t of  the  e x p l i c i t t h a t s e n i o r management,  d i r e c t o r s , f i r s t l i n e nurse managers and  staff,  and  72  p h y s i c i a n s were a l l n e e d i n g i n c r e a s e d s u p p o r t . The f i r s t l i n e nurse managers s t r a t e g i z e d how  t h e y might  g i v e as w e l l as r e c e i v e s u p p o r t i n t i m e s o f change. Summary F i r s t l i n e nurse managers d e s c r i b e d  creative  s t r a t e g i e s t o d e a l w i t h the changes brought on by f i s c a l c o n s t r a i n t s . However, t h e y c l a i m e d t h a t managing change r e q u i r e d money t o be spent on t e c h n o l o g y and c l e r i c a l a s s i s t a n c e t h a t was  c u r r e n t l y l a c k i n g . The  f i r s t l i n e nurse managers suggested t h a t  information  systems were needed t o p r o c e s s the massive amount o f p a t i e n t d a t a i n a u s e f u l way. b o t h f i n a n c i a l and p e r s o n a l , managers was  lacking.  A d m i n i s t r a t i v e support, for f i r s t line  nurse  The f i r s t l i n e nurse managers  agreed t h a t p e r s o n a l s u p p o r t from s e n i o r management was not l i k e l y t o i n c r e a s e and, t h e r e f o r e , i t was more i m p o r t a n t than ever t o support each  other.  Chapter Summary The e n o r m i t y o f changes w i l l  c o n t i n u e i n the  h e a l t h c a r e i n d u s t r y f o r some time t o come. The will  c o n t i n u e t o be r a p i d and f o r e i g n even t o  f i r s t l i n e nurse managers.  The impact w i l l  changes seasoned  continue to  a f f e c t the p r a c t i c e o f f i r s t l i n e nurse managers i n a l l  73 aspects of t h e i r r o l e .  Whether the impact i s w o r k l o a d ,  l a c k of t i m e l y i n f o r m a t i o n , or u n c e r t a i n t y , i t i s the f u t u r e . How  the f i r s t l i n e nurse managers are g o i n g t o  s u r v i v e i n the r a p i d l y changing h e a l t h care c l i m a t e i s a m a t t e r of managing the changes.  S t r a t e g i e s used t o  date have been c r e a t i v e but not enough i n themselves t o continue  t o manage f u t u r e changes. There are no  text  book answers, but the f i r s t l i n e nurse managers recognized  that supporting  t h e i r colleagues  i m p o r t a n t s t e p i n managing the changes t h a t r e s t r a i n t has  imposed on t h e i r p r a c t i c e .  was  an  fiscal  74  CHAPTER 5: SUMMARY, CONCLUSIONS, AND IMPLICATIONS  A summary o f t h e s t u d y i s p r e s e n t e d and c o n c l u s i o n s drawn from t h e f i n d i n g s a r e d i s c u s s e d i n this section.  As w e l l , t h e i m p l i c a t i o n s f o r  administrative nursing p r a c t i c e , research, education, and h o s p i t a l a d m i n i s t r a t o r s w i l l - be o u t l i n e d . Summary The purpose o f t h i s s t u d y was t o examine t h e p e r c e p t i o n s o f f i r s t l i n e nurse managers o f managing w i t h i n a c l i m a t e o f f i s c a l r e s t r a i n t . Canada's h e a l t h c a r e system w i l l c o n t i n u e t o be i n f l u e n c e d by t h e economic c l i m a t e d u r i n g t h e next decade.  First  line  nurse managers p l a y a p i v o t a l r o l e i n t h e q u a l i t y o f the c a r e d e l i v e r e d t o p a t i e n t s . T h e r e f o r e , i t i s i m p o r t a n t t h a t r e s e a r c h be conducted  t o determine  how  they manage t h e d e l i v e r y o f p a t i e n t c a r e w i t h i n a climate of f i s c a l  restraint.  Reports i n the l i t e r a t u r e i n d i c a t e t h a t e a r l y advocates  f o r h e a l t h c a r e r e f o r m t o c o n t r o l c o s t s were  i g n o r e d by governments as r e f o r m was p o l i t i c a l l y unpopular.  However, h e a l t h c a r e r e f o r m i s now a major  focus o f b o t h p r o v i n c i a l and f e d e r a l governments as  75 t h e y s t r u g g l e t o c o n t r o l t h e s p i r a l l i n g Canadian deficit. The l i t e r a t u r e i n d i c a t e s t h a t t h e f i r s t l i n e  nurse  manager's r o l e c o n t i n u e s t o e v o l v e , and i t i s i n c r e a s i n g i n a c c o u n t a b i l i t y and r e s p o n s i b i l i t y , p a r t i c u l a r l y i n the area of f i n a n c i a l  responsibility.  A l s o , f i r s t l i n e nurse managers s t r o n g l y i n f l u e n c e t h e q u a l i t y o f c a r e t h a t i s d e l i v e r e d i n Canadian hospitals.  Thus, i t i s t h e f i r s t l i n e nurse managers  who have r e s p o n s i b i l i t y o f e n s u r i n g t h a t p a t i e n t s r e c e i v e h i g h q u a l i t y c a r e i n a c o s t e f f e c t i v e manner. A d e s c r i p t i v e e x p l o r a t o r y d e s i g n was used t o examine t h e p e r c e p t i o n s o f f i r s t l i n e nurse managers o f managing w i t h i n a c l i m a t e o f f i s c a l r e s t r a i n t .  This  s t u d y i s p a r t o f a l a r g e r s t u d y by A c o r n and Crawford (1995) i n which d a t a were c o l l e c t e d through a survey, completed by 200 f i r s t l i n e nurse managers i n 38 acute care h o s p i t a l s i n B r i t i s h In to  Columbia.  t h e c u r r e n t study, focus groups were  conducted  v a l i d a t e t h e d a t a c o l l e c t e d by t h e open-ended  q u e s t i o n s i n t h e A c o r n and Crawford s t u d y and t o f u r t h e r explore the perceptions of f i r s t l i n e  nurse  managers o f managing w i t h i n a c l i m a t e o f f i s c a l  76  restraint. The d a t a c o l l e c t e d from the f o c u s groups were r e c o r d e d , t r a n s c r i b e d v e r b a t i m , and a n a l y z e d u s i n g c o n t e n t a n a l y s i s . Content a n a l y s i s i s a s t r a t e g y f o r a n a l y z i n g r e c o r d e d d a t a i n which i t i s f i r s t  coded,  c l u s t e r e d , then o r g a n i z e d under c a t e g o r i e s from  which  themes b e g i n t o emerge. The  f i n d i n g s i n d i c a t e t h a t the h e a l t h c a r e  i n d u s t r y i n Canada i s r a p i d l y changing and i n complexity.  increasing  These changes are c r e a t i n g major  c h a l l e n g e s f o r f i r s t l i n e nurse managers i n meeting  the  s t a n d a r d s f o r q u a l i t y p a t i e n t c a r e i n an environment o f dwindling resources. Three themes emerged from the f o c u s group d a t a : e n o r m i t y o f change, impact o f change, and management o f change.  The  f i r s t l i n e nurse managers i n d i c a t e d t h a t  the e n o r m i t y o f change r e s u l t e d from h e a l t h c a r e r e f o r m , d e c e n t r a l i z a t i o n o f d e c i s i o n making, i n c r e a s e i n a c c o u n t a b i l i t y and r e s p o n s i b i l i t y , and changes t o the d e l i v e r y o f p a t i e n t c a r e .  The  first line  nurse  managers b e l i e v e d t h a t h e a l t h c a r e r e f o r m i s n e c e s s a r y to  contain costs.  However, the managers p e r c i e v e d t h a t  p a t i e n t s w i l l o n l y b e n e f i t from h e a l t h c a r e r e f o r m i f  77 funding  i s r e d i s t r i b u t e d t o a g e n c i e s t h a t can p r o v i d e  the b e s t s e r v i c e a t t h e l e a s t c o s t . D e c e n t r a l i z a t i o n o f d e c i s i o n making was viewed as a p o s i t i v e management s t r a t e g y as i t was seen t o expedite u n i t l e v e l d e c i s i o n s that b e n e f i t e d both p a t i e n t s and s t a f f . A c c o u n t a b i l i t y and c o n t r o l p r o v e d t o be p r o b l e m a t i c t o t h e f i r s t l i n e nurse managers as the a u t h o r i t y and c o n t r o l d i d n o t match t h e i r scope o f r e s p o n s i b i l i t y , t h e r e f o r e , making i t e x t r e m e l y difficult  f o r them t o ensure c o s t e f f e c t i v e q u a l i t y  p a t i e n t care.  The f i r s t l i n e nurse managers i n d i c a t e d  t h a t t h e changes t o c a r e d e l i v e r y p r a c t i c e s have r e s u l t e d i n c o s t b e n e f i t s . They b e l i e v e d t h a t  shorter  l e n g t h s o f h o s p i t a l s t a y and fewer i n v a s i v e p r o c e d u r e s b e n e f i c i a l f o r most p a t i e n t s .  However, t h e r e was  c o n c e r n t h a t some p a t i e n t s would n o t b e n e f i t from t h e changes and, i n f a c t , p a t i e n t outcomes might be worse. These sub-themes a r e c o n s i s t e n t w i t h r e p o r t s i n t h e literature. The impact o f change posed d i f f i c u l t i e s f o r t h e f i r s t l i n e nurse managers i n t h a t t h e y r e p o r t e d an i n c r e a s e i n w o r k l o a d , l e s s e f f e c t i v e communication, and uncertainty of t h e i r future r o l e i n health care.  The  78  u n c e r t a i n t y stemmed from t h e i r c o n c e r n t h a t t h e y might be r e p l a c e d by non-nurse managers w i t h advanced l e v e l s of e d u c a t i o n w i t h a b u s i n e s s  focus.  Although senior  administrators' educational expectations l i n e nurse manager's p o s i t i o n had  f o r the  first  increased, there  was  l i t t l e support from s e n i o r a d m i n i s t r a t o r s t o o b t a i n same. The  the  uncertainty regarding t h e i r r o l e p a r t i c u l a r l y  concerned the f i r s t l i n e nurse managers because o f p o t e n t i a l negative  the  impact t h i s might have on p a t i e n t  care. Many s t r a t e g i e s were proposed by the f i r s t  line  nurse managers f o r managing change w i t h i n a c l i m a t e of f i s c a l r e s t r a i n t . The  l a c k of t e c h n o l o g i c a l  and  a d m i n i s t r a t i v e support systems were seen t o pose p a r t i c u l a r l y d i f f i c u l t challenges nurse managers.  f o r the f i r s t  Management o f change was  line  a l s o seen t o  r e q u i r e s u p p o r t from f i r s t l i n e nurse managers' colleagues, senior h o s p i t a l administrators  and  t e c h n o l o g i c a l advances. A s i g n i f i c a n t s u p p o r t system t h e y i d e n t i f i e d was recognized  t h e i r own  c o l l e a g u e s which t h e y  as a r i c h , but u n d e r u l i l i z e d r e s o u r c e .  79 Conclusions The  following conclusions  were d e r i v e d  from t h e  f i n d i n g s o f t h e study: 1) The h e a l t h c a r e environment i n B r i t i s h Columbia i s r a p i d l y changing, a d d i n g t o t h e c o m p l e x i t y o f d e l i v e r i n g q u a l i t y care i n a constrained  economic  environment. 2)  F i r s t l i n e nurse managers' a c c o u n t a b i l i t y and  r e s p o n s i b i l i t i e s are i n c r e a s i n g p a r t i c u l a r l y regards to f i n a n c i a l  with  accountability.  3) O v e r a l l changes t o c a r e d e l i v e r y p r a c t i c e s a r e b e l i e v e t o have p o s i t i v e outcomes f o r p a t i e n t s ; however, t h e outcomes need t o be measured more extensively. 4) F i r s t l i n e nurse managers a r e concerned about b e i n g replaced  by n o n - n u r s i n g managers because  nursing  knowledge i s e s s e n t i a l when making d e c i s i o n s  with  r e g a r d s t o changes i n c a r e d e l i v e r y p r a c t i c e s . 5) The l e v e l o f t e c h n o l o g i c a l  and a d m i n i s t r a t i v e  s u p p o r t a v a i l a b l e t o f i r s t l i n e nurse managers i n managing change i s inadequate c r e a t i n g an a d d i t i o n a l s t r e s s o r which adds t o t h e burden o f managing change.  80  Implications The f i n d i n g s o f the s t u d y have i m p l i c a t i o n s f o r administrative nursing p r a c t i c e , education, research, and h o s p i t a l a d m i n i s t r a t o r s as d i s c u s s e d below. Administrative Nursing Practice The r o l e o f the f i r s t l i n e nurse manager i s expanding  i n scope, a c c o u n t a b i l i t y ,  responsibility,  and, p a r t i c u l a r l y , i n the a r e a o f f i n a n c i a l accountability.  T h i s c h a l l e n g e s the f i r s t l i n e  manager t o p o s s e s s s k i l l s o f c l i n i c a l specialized field,  nurse  expertise i n a  t o have an u n d e r s t a n d i n g o f the  economic c l i m a t e , and knowledge o f b u s i n e s s p l a n s , w h i l e keeping a b r e a s t o f t e c h n o l o g y and i n n o v a t i v e ways to  s t r e a m l i n e c a r e d e l i v e r y systems. The s k i l l s  of  f i n a n c i a l a n a l y s i s and management as w e l l as negotiation, c o n f l i c t r e s o l u t i o n , labour r e l a t i o n s ,  and  l e a d e r s h i p need t o be enhanced. G i v e n the need f o r the s k i l l s d e s c r i b e d above, the f o l l o w i n g i s s u e s s h o u l d be addressed by nurse a d m i n i s t r a t o r s / f i r s t l i n e nurse managers.  First,  does one i n t h i s p o s i t i o n a c q u i r e the n e c e s s a r y  how skills?  What are f i r s t l i n e nurse managers' r e s p o n s i b i l i t i e s v e r s u s those o f a d m i n i s t r a t i o n i n p r o v i d i n g support t o  81 i d e n t i f y the necessary  s k i l l s needed i n a changing  environment? What r o l e does a d m i n i s t r a t i o n p l a y i n p r o v i d i n g the opportunity f o r education versus the i n d i v i d u a l ' s own r e s p o n s i b i l i t y t o i d e n t i f y and a c q u i r e the  skills? Second, how does a d m i n i s t r a t i o n determine t h e  c r i t e r i a needed t o s e l e c t t h i s i n d i v i d u a l i n a changing environment? ( i . e . , when t h e s k i l l changing)?  sets are r a p i d l y  What i s t h e most a p p r o p r i a t e way t o  provide the s k i l l s ,  g i v e n t h e r a p i d n a t u r e o f change?  For example, i s t h i s an i s s u e f o r h o s p i t a l s o r e d u c a t i o n a l i n s t i t u t i o n s o r both?  These q u e s t i o n s have  potential implications f o r nursing  education.  Nursing  Education  The c h a l l e n g e f o r nurse e d u c a t o r s  i s t o respond t o  the demands t h a t t h e r a p i d l y changing h e a l t h c a r e environment i s p l a c i n g on i n d i v i d u a l s i n / o r i n t e r e s t e d i n f i r s t l i n e nurse manager p o s i t i o n s . to  C u r r i c u l a need  focus on a d m i n i s t r a t i v e s k i l l s , b u s i n e s s o r  f i n a n c i a l management, t r e n d s i n h e a l t h c a r e ,  people  management, change management, and n u r s i n g p r a c t i c e i n the c o n t e x t o f today's h e a l t h c a r e . To meet a l l o f these requirements  poses many l o g i s t i c a l  problems f o r  82  educators.  For example, how  would a c u r r i c u l u m  be  d e v e l o p e d t o meet t h e s e needs w i t h o u t making the programs so l e n g t h y and c o s t l y t h a t t h e y would be impractical?  How  do programs meet the needs of  i n d i v i d u a l s a l r e a d y i n management p o s i t i o n s as opposed t o those i n d i v i d u a l s i n t e r e s t e d i n p u r s u i n g n u r s i n g management?  a career  These are i m p o r t a n t q u e s t i o n s  in  that  are i n need of e a r l y a t t e n t i o n . In the focus groups, the f i r s t l i n e nurse managers suggested t h a t graduate n u r s i n g programs preceptorships  f o r new  incorporate  managers. They a l s o suggested  t h a t t h e r e were not enough e d u c a t i o n a l  opportunities  w i t h i n the h o s p i t a l s t o s u p p o r t managers c u r r e n t l y i n positions. The  f i n d i n g s i n d i c a t e d t h a t the f i r s t l i n e nurse  managers were concerned t h a t non-nurses would  replace  f i r s t l i n e nurse managers because t h e y p o s s e s s more business s k i l l s .  To p r e v e n t t h i s from o c c u r r i n g ,  f i r s t l i n e nurse managers i d e n t i f i e d  t h a t i t would be  advantageous t o a c q u i r e the n e c e s s a r y b u s i n e s s t o meet the demands o f the p o s i t i o n . t h a t t h e r e i s a need f o r c o u r s e s i n management r a t h e r than an MBA.  the  skills  They i n d i c a t e d financial  However, t h e y a l s o  83  suggested t h a t i t was a d i f f i c u l t b a l a n c i n g a c t t o manage t h e i r workloads i n the i n c r e a s i n g l y demanding environment and, s i m u l t a n e o u s l y ,  t o meet t h e i r  educational requirements. Nursing  Research  Research on the e v o l v i n g r o l e o f f i r s t l i n e nurse managers i s l i m i t e d , p a r t i c u l a r l y i n Canada.  Findings  i n d i c a t e d t h a t the f i r s t l i n e nurse managers' areas o f r e s p o n s i b i l i t y d i f f e r e d i n p a t i e n t p o p u l a t i o n , number of beds, s t a f f and a c t u a l budget amounts, but t h a t the m a n a g e r i a l i s s u e s were s i m i l a r . For  example,  e d u c a t i o n a l i s s u e s around f i n a n c i a l p l a n n i n g and human resources  ( s u p p o r t i n g o t h e r s i n times o f change, and  l a b o u r r e l a t i o n s i s s u e s ) were concerns f o r a l l o f them. F u r t h e r r e s e a r c h i s needed on the r o l e of f i r s t  line  nurse managers i n the Canadian h e a l t h care system o r , more s p e c i f i c a l l y ,  f i r s t l i n e nurse managers i n B r i t i s h  Columbia. Research on m a s t e r ' s - p r e p a r e d n u r s e s c u r r e n t l y i n f i r s t l i n e manager p o s i t i o n s s h o u l d compare t y p e s o f programs ( i . e . , master's i n n u r s i n g a d m i n i s t r a t i o n and master's i n b u s i n e s s a d m i n i s t r a t i o n ) and What are the p e r c e p t i o n s  performance.  o f managers o f how  their  84  programs have a s s i s t e d them i n t h e i r c u r r e n t p o s i t i o n s ? Nurses need t o s t u d y t h e impact o f changes i n care d e l i v e r y p r a c t i c e s f o r example, i f e a r l y d i s c h a r g e i s accomplished i s the p a t i e n t being readmitted  at other  f a c i l i t i e s ? A r e s e v i c e s r e q u i r e d i n t h e community f o r p a t i e n t s who a r e d i s h a r g e d e a r l y and, i f so, a r e they available.  L a s t l y , t h i s study needs t o be  repeated  u s i n g a l a r g e r sample s i z e and i n c l u d i n g h o s p i t a l s o u t s i d e t h e Lower  Mainland.  Hospital Administrators In times o f change, p a r t i c u l a r l y when  resources  are l i m i t e d , h o s p i t a l a d m i n i s t r a t o r s must draw t o an even g r e a t e r e x t e n t on v a l u a b l e human r e s o u r c e s .  The  f i r s t l i n e nurse managers a r e a v a l u a b l e a s s e t because of t h e key r o l e they p l a y i n t h e p r o v i s i o n o f q u a l i t y cost effective' p a t i e n t care.  Hospital administrators  need t o work c o l l a b o r a t i v e l y w i t h t h e i r f i r s t  line  nurse managers t o ensure t h a t p a t i e n t care i s n o t compromised d u r i n g t h e r a p i d l y changing  fiscally  r e s t r a i n e d environment. Resource a l l o c a t i o n i s an i n c r e a s i n g l y complex p r o c e s s restraint.  i n times o f f i s c a l  H o s p i t a l a d m i n i s t r a t o r s may draw on f i r s t  l i n e nurse managers' c l i n i c a l e x p e r t i s e so t h a t  85 resources  a r e not wasted and a r e r e d i s t r i b u t e d t o where  t h e y can be u t i l i z e d most e f f e c t i v e l y .  This  should  i n c l u d e e n s u r i n g t h a t f i r s t l i n e nurse managers a r e r e c e i v i n g t h e s u p p o r t t h e y need t o m a i n t a i n o r improve the q u a l i t y and c o s t e f f e c t i v e n e s s o f p a t i e n t c a r e . I n c o n c l u s i o n , t h i s study has examined t h e perceptions  o f f i r s t l i n e nurse managers o f managing  w i t h i n a c l i m a t e o f f i s c a l r e s t r a i n t . The f i n d i n g s i n d i c a t e t h e complex c h a l l e n g e s w i t h which f i r s t nurse managers d e a l .  The study p r o v i d e s  line  direction for  f i r s t l i n e nurse managers and h o s p i t a l a d m i n i s t r a t o r s who a r e r e s p o n s i b l e f o r d e l i v e r i n g q u a l i t y p a t i e n t i n a changing and f i s c a l l y c h a l l e n g i n g environment.  care  86  References  A c o r n , S., & Crawford, M. ( 1 9 9 5 ) .  Decentralized  o r g a n i z a t i o n a l s t r u c t u r e s and f i r s t l i n e nurse managers. J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n ,  25(10),  5,27.  B a x t e r , E. ( 1 9 9 3 ) . Head n u r s e s '  perceptions of  t h e i r r o l e s : P a r t 1 & P a r t 1 1 . Canadian J o u r n a l o f Nursing A d m i n i s t r a t i o n , 6 { 3 ) , 7-16. Canadian Nurses A s s o c i a t i o n . ( 1 9 8 8 ) . The r o l e o f the nurse a d m i n i s t r a t o r and s t a n d a r d s f o r n u r s i n g a d m i n i s t r a t i o n . Ottawa; A u t h o r . Canadian Nurses A s s o c i a t i o n . (1993) time o f change: The c h a l l e n g e  Leading i n a  f o r the nursing  p r o f e s s i o n . Ottawa: A u t h o r . C a r r o l l , T. L., & Adams, B. A. ( 1 9 9 4 ) . The work and s e l e c t i o n o f f i r s t - l i n e nurse managers: 1 9 8 2 - 1 9 9 2 . Journal of Nursing A d m i n i s t r a t i o n , 2 4 ( 5 ) ,  16-21.  Chase, L. ( 1 9 9 4 ) . Nurse manager competencies. Journal of Nursing Administration, 24(45),  56-64.  87 C o l l i n s , A. L., & Noble, R. (1992). H o s p i t a l rightsizing:  I n l i n e With l o n g - t e r m s t r a t e g i e s and  economic r e a l i t i e s . H e a l t h c a r e Management Forum, 5(1),  4-10. Crawford, M, & A c o r n , S. ( I n p r e s s ) . F i r s t  nurse managers: Scope o f r e s p o n s i b i l i t y fiscal restraint.  line  i n a time o f  Journal of Nursing Administration.  Crummer, M. B., & C a r t e r , v. (1993). C r i t i c a l pathways: The p i v o t a l  t o o l . Journal of Cardiovascular  N u r s i n g , 7 ( 4 ) , 30-37. D i c k , J . (1992). ( E d i t o r i a l )  N u r s i n g economics i n  Canada. Canadian J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , 5(2),  6-7. D i c k , J . , & Bruce. S. (1994). Cost  Doing more w i t h l e s s .  containment:  I n J . M. H i b b e r d & E. M. K y l e  (Eds.), N u r s i n g management i n Canada (pp. 91-107). Toronto: W. B.  Saunders.  Eubanks, P. (1992). The new nurse manager: A linchpin  i n quality  66(8), 22-30.  c a r e and c o s t c o n t r o l .  Hospitals,  88 F u l l e r t o n , M. educational  ( 1 9 9 3 ) . The c h a n g i n g r o l e  requirements of the f i r s t - l i n e  manager. C a n a d i a n J o u r n a l 6(4),  of Nursing  nurse  Administration,  20-24. H e n r y , B.  (1992). C h a r a c t e r i s t i c s o f nurse  managers i n community and m e t r o p o l i t a n  teaching  h o s p i t a l s : A comparative study. Nursing Quarterly,  17(1),  & Copper, J . (1987).  n u r s e s : T h e i r p r a c t i c e and e d u c a t i o n . Nursing  Administration  74-75  Hodges, L.C., Knapp, R.,  Administration,  K r u e g e r , R. A.  Journal  Head  of  3/7(12), 39-44.  (1994). Focus groups: A  guide f o r a p p l i e d research CA:  and  practical  (2nd e d . ) . T h o u s a n d Oaks,  Sage. Manga, P.  ( 1 9 9 2 ) . The e c o n o m i c c r i s i s  Canadian Journal  of Nursing  and  nursing.  Administration, 5(2),  17-19. M a r k , B. A. manager: Journal  ( 1 9 9 4 ) . The e m e r g i n g r o l e o f t h e n u r s e  Implications of Nursing  f o r educational  Administration,  preparation.  2_4(1), 4 8 - 5 5 .  89  McCloskey, J . C ,  Gardner, D., Johnson, M., &  Mass, M . ( 1 9 8 8 ) . What i s t h e s t u d y o f n u r s i n g s e r v i c e administration? Journal of P r o f e s s i o n a l Nursing, 4(2),  92-98.  M i l e s , B. M., & Huberman, A. M.  (1994).  Q u a l i t a t i v e d a t a a n a l y s i s (2nd e d . ) . Thousand Oaks, CA: Sage. Mintzberg,  H. ( 1 9 7 3 ) . The n a t u r e o f m a n a g e r i a l  work. New York: Harper and Row. Mish,  F. C. (Ed.).  ( 1 9 8 3 ) . Webster's n i n t h new  c o l l e g i a t e d i c t i o n a r y . ( 9 t h e d . ) . Markham, O n t a r i o : Thomas A l l e n & Son Morgan, D. L. (Ed.).  (1993).  Successful  focus  groups: A d v a n c i n g t h e s t a t e o f t h e a r t . Newbury Park, CA: Sage. O ' B r i e n - P a l l a s , L. ( 1 9 9 2 ) . Overview o f n u r s i n g r e s e a r c h i n h e a l t h c a r e w i t h i n t h e c u r r e n t economic c o n t e x t . Canadian J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , 5(2),  20-24.  P o l i t , D. F., & Hungler, B. P. ( 1 9 9 5 ) . r e s e a r c h : P r i n c i p l e s and methods ( 5 t h Philadelphia: Lippincott.  ed.).  Nursing  90 R a c h l i s , M., m e d i c i n e : How  (1994).  Strong  t o save Canada's h e a l t h c a r e  Toronto: Harper Roch, D.  & Kushner, C.  system.  Collins. (1992). Overview o f h e a l t h c a r e  r e s t r u c t u r i n g w i t h i n c u r r e n t r e s o u r c e s . Canadian J o u r n a l of Nursing A d m i n i s t r a t i o n , 5(2), S o v i e , D. M.  8-11.  (1994). Nurse manager: A key r o l e i n  c l i n i c a l outcomes. N u r s i n g Management, 2 5 ( 3 ) , 30-34. W a l t z , C. F.,  S t r i c k l a n d , E. R.,  & Lenz, E.  R.  (1984). Measurement i n n u r s i n g r e s e a r c h (2nd e d . ) . P h i l a d e l p h i a : F. A. W e l l s , G. T.  Davis.  (1990). I n f l u e n c e o f o r g a n i z a t i o n a l  s t r u c t u r e on nurse manager j o b s a t i s f a c t i o n . N u r s i n g A d m i n i s t r a t i o n Q u a r t e r l y , 1_4(4),  1-8.  91  Appendix A  Demographics Age a t l a s t b i r t h d a y Highest e d u c a t i o n a l l e v e l : N u r s i n g Diploma N u r s i n g Diploma w i t h a d d i t i o n a l certificate/courses B a c c a l a u r e a t e Degree i n N u r s i n g B a c c a l a u r e a t e Degree Other Masters Degree i n N u r s i n g Masters Degree Other Years of e x p e r i e n c e as a f i r s t l i n e nurse manager: Completed q u e s t i o n n a i r e i n S p r i n g 1994: yes No Thank you f o r your p a r t i c i p a t i o n i n t h i s focus group i n t e r v i e w .  Appendix B Survey Q u e s t i o n s 1. A c l i m a t e o f f i s c a l r e s t r a i n t i n c l u d i n g c u t s , d o w n s i z i n g / r i g h t s i z i n g , r e g i o n a l i z a t i o n of h e a l t h care and the move t o p r o v i d i n g h e a l t h c a r e " c l o s e r t o home" i s p r e s e n t i n many a g e n c i e s . L i s t 3 (or more) ways the p r e s e n t c l i m a t e o f f i s c a l r e s t r a i n t has had an impact on your r o l e as a f i r s t l i n e nurse manager. 2 . P l e a s e i d e n t i f y s t r a t e g i e s t h a t you have implemented or are p l a n n i n g t o implement t o work more e f f e c t i v e l y w i t h l i m i t e d r e s o u r c e s (e.g., h o s p i t a l - c o m m u n i t y p a r t n e r s h i p programs, development o f j o i n t o r c o l l a b o r a t i v e d e p a r t m e n t a l programs w i t h i n your f a c i l i t y etc.). 3. P l e a s e l i s t the f a c t o r s which would make your j o b as a f i r s t l i n e nurse manager e a s i e r i n t h i s p r e s e n t f i s c a l c l i m a t e ( e x c l u d i n g more money). Adapted from A c o r n , S.,  & C r a w f o r d , M.  (1995).  D e c e n t r a l i z e d o r g a n i z a t i o n a l s t r u c t u r e s and f i r s t nurse managers. J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , 25(10),  5,  27.  line  93 Appendix C  FOCUS GROUP INTERVIEW QUESTIONS RESEARCH QUESTION: WHAT ARE THE PERCEPTIONS OF FIRST LINE NURSE MANAGERS OF MANAGING WITHIN A CLIMATE OF FISCAL RESTRAINT? TRIGGER QUESTIONS: H e a l t h c a r e r e f o r m has l a r g e l y been s p u r r e d on by the present climate of f i s c a l r e s t r a i n t that i s p r e d i c t e d to c o n t i n u e as governments s t r u g g l e t o c o n t r o l d e f i c i t s and c o n t a i n c o s t s . The purpose o f t h i s group i n t e r v i e w i s t o hear what "you" as f i r s t l i n e nurse managers have t o say about managing i n a c l i m a t e o f f i s c a l r e s t r a i n t . 1. T h e r e f o r e , t h i n k i n g back o v e r the p a s t few months can you t e l l me what the impact the c l i m a t e of f i s c a l r e s t r a i n t has had on your r o l e as a f i r s t l i n e nurse manager? Probe: P l e a s e e l a b o r a t e on how f i s c a l r e s t r a i n t has i n f l u e n c e d your w o r k l o a d . Probe: P l e a s e e l a b o r a t e on the impact the p r e s e n t c l i m a t e o f f i s c a l r e s t r a i n t has had on your s t a f f . 2. What impact i s the c l i m a t e o f f i s c a l h a v i n g on p a t i e n t c a r e ?  restraint  3. P l e a s e d e s c r i b e the s t r a t e g i e s t h a t you as a nurse manager have implemented o r are p l a n n i n g t o implement on your u n i t s t o work more e f f e c t i v e l y w i t h l i m i t e d resources. 4. What would make your j o b as a f i r s t l i n e nurse manager e a s i e r i n the p r e s e n t c l i m a t e o f f i s c a l r e s t r a i n t ( e x c l u d i n g more money)? Probe: P l e a s e e l a b o r a t e on the i s s u e o f autonomy. Probe: P l e a s e e l a b o r a t e on the i n t e r d i s c i p l i n a r y w o r k i n g r e l a t i o n s h i p s i n your a r e a . Are t h e r e any o t h e r p o i n t s you would l i k e t o r a i s e ?  94 Appendix D: Consent  Form  THE UNIVERSITY OF BRITISH COLUMBIA School of  Nursing  T206-2211 Wesbrook M a l l Vancouver, BC V6T 2B5 T e l : ( 6 0 4 ) 822-7417 Fax:(604) 822-7466  I u n d e r s t a n d the purposes o f t h i s s t u d y , " D e c e n t r a l i z e d O r g a n i z a t i o n a l S t r u c t u r e s and F i r s t L i n e Nurse Managers", a r e t o examine 1) f i s c a l r e s t r a i n t , c u l t u r a l l y d i v e r s e environments, and t e c h n o l o g y as f a c t o r s c o n t r i b u t i n g t o o r g a n i z a t i o n a l c o m p l e x i t y and 2) the r e l a t i o n s h i p s between d e c e n t r a l i z a t i o n and j o b s a t i s f a c t i o n , o r g a n i z a t i o n a l commitment, and p r o f e s s i o n a l autonomy o f f i r s t l i n e n u r s e managers. Data have a l r e a d y been c o l l e c t e d t h r o u g h a s e l f a d m i n i s t e r e d q u e s t i o n n a i r e . T h e r e f o r e , f o c u s group i n t e r v i e w s w i l l be conducted t o e x p l o r e the f a c t o r s c o n t r i b u t i n g t o o r g a n i z a t i o n a l c o m p l e x i t y i n f u r t h e r depth. I u n d e r s t a n d t h a t I w i l l be asked t o p a r t i c i p a t e i n a f o c u s group i n t e r v i e w , conducted by C l a i r e O'Quinn, t o e x p l o r e the i s s u e s s u r r o u n d i n g managing i n a c l i m a t e o f f i s c a l r e s t r a i n t . S i x t o e i g h t f i r s t l i n e nurse managers w i l l p a r t i c i p a t e i n t h i s f o c u s group i n t e r v i e w which w i l l not exceed two hours i n d u r a t i o n . The i n t e r v i e w w i l l be tape r e c o r d e d f o r t r a n s c r i p t i o n i n t o w r i t t e n format a t a l a t e r t i m e . Once the i n t e r v i e w s are t r a n s c r i b e d , the tapes w i l l be d e s t r o y e d . My name and any i d e n t i f y i n g i n f o r m a t i o n w i l l not be r e v e a l e d i n the s t u d y . C o n f i d e n t i a l i t y has been a s s u r e d because a code number known o n l y t o C l a i r e O'Quinn and the two c o - r e s e a r c h e r s w i l l i d e n t i f y the tapes and w r i t t e n c o p i e s o f the r e c o r d e d i n f o r m a t i o n . I am under no o b l i g a t i o n t o p a r t i c i p a t e i n t h i s s t u d y and r e f u s a l to p a r t i c i p a t e w i l l not a f f e c t my employment i n any way. I u n d e r s t a n d t h a t I f I p a r t i c i p a t e , I can withdraw a t anytime, r e f u s e t o answer any q u e s t i o n s o r ask t o have p a r t o r a l l o f the tape e r a s e d . I w i l l r e c e i v e a copy o f t h i s form. A l l my q u e s t i o n s have been answered and i f I have any f u r t h e r q u e s t i o n , I can c o n t a c t C l a i r e O'Quinn a t XIX-XXXX o r the cor e s e a r c h e r s : Dr. S o n i a A c o r n , XIX-XXXX; Ms. M a r i l y n Crawford, XIX-XXXX. Date:  Signature:  I u n d e r s t a n d the n a t u r e o f t h i s s t u d y and g i v e my consent t o participate. Date: I acknowledge  Signature: r e c e i p t o f a copy o f t h i s consent Form.  

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