Office of the Chief Nursing Officerwww.health.qld.gov.au/ocno      Review of the Nurse Unit Manager Role      Final report...
Review of the Nurse Unit Manager RoleFinal reportSeptember 2008Queensland HealthOffice of the Chief Nursing OfficerReview ...
Contents	          Terms and abbreviations used	                                                 3	          Executive sum...
Terms and abbreviations used	 ACIRRT	                  Australian Centre for Industrial		                         Relation...
Executive summaryThis report details the findings from the Nurse Unit Manager (NUM) Project undertaken andresourced by the...
The aim of this report is to highlight the vital role of the NUM with the aim of strengthening theenablers that support th...
Key issuesThe following issues were identified by NUMs who took part in the consultation groups across thestate. These are...
Recommendations for NUM roleFunding will need to be sourced for the implementation of the following recommendationsaddress...
Recommendation 3:That by reviewing the role of the NUM it is recognised that this will have an impact on othergrades withi...
Recommendation 6: – Identify key issuesThat the NUMs clinical leadership role is supported by mobile technological support...
•	 Registered Nurses Grade 5 and 6 identified through Performance Assessment and 		  	 Development Process (PAD) as intere...
Risk to QH of not implementing recommendation 9:	 •	 That the inflexibility of work practices makes a significant impact o...
2.0	 Introduction2.1	      Background to projectThis report details the outcomes of a six month project conducted and fund...
widely acknowledged Queensland Health2 is experiencing difficulty in recruiting and retainingNUMs when their job satisfact...
The Queensland Health report ‘better workplaces’ Staff Opinion Survey (2007)6 also recognisespsychological factors effect ...
2.3	     Project limitationsThe project is relatively modest in its aims and scope.Data to support the definitive number o...
3.0	 Methodology1.	   Literature review of international, inter state and state wide research and peer reviewed 			     ar...
3.2.2 	 Consultation Groups17 Groups consisting of 5-15 acting and permanently appointed NUMs met across the state andtook...
4.0	 Review findings4.1	   Themes emerging from the consultation groupsThe key themes which emerged from questionnaires an...
•	 Leading the team		 •	 Professional development		 •	 Change managementOther (mainly rural and remote but not limited to ...
•	 Inconsistencies in the role across QH	 •	 Lack of staff:		 –	 Recruitment processes are long and time consuming		 –	 Sh...
4.5 	 Questionnaire resultsQuestionnaires were completed at a return rate of 96% (n= 154).Of the 154 responses, 32 (21%) i...
Graph 2: The respondent sample was asked to list number of years in the NUM role.       25       20       15              ...
NUMs were asked to indicate what was the highest level of education they had obtained, andif they had found that education...
Discussion summaryIt was evident through comments made in consultation groups that for the majority of theparticipants, mo...
There is a strong argument for optimising the role of the NUM by making better use of the skillsof the NUM to affect patie...
The opportunity to network and derive support from meeting their peers formally was providedthrough the consultation group...
experienced within the NUM role across Queensland Health currently where a NUM who has asmall staff and works office hours...
Strategies need to be put in place to ensure NUMs develop the business knowledge and otheressential skills for the role25....
NUMs who had worked in other states/territories suggested an Associate NUM role which wouldassist with both workload and s...
ConclusionThe NUM role has expanded in scope to the degree it is now recognised as being difficult torecruit and retain hi...
Appendix 1:	A full description of the perceived current responsibilities		          of the NUMClinical leadership         ...
Appendix 2: Desirable skills and attributes (formal and informal)Personal characteristics Formal qualifications       Orie...
Appendix 3: Barriers and Enablers to performing roleBarriersNo specific orientation to role,                          Lack...
Appendix 4:Nurse Unit Manager Project questionnaire – pre consultation groupsThis questionnaire is designed to form the ba...
Appendix 5: Ideal role – ideas from consultation groups Clinical                         Succession planning/education    ...
Appendix 6: Core purpose of NUM roleCore purpose of NUM role                                                              ...
References1.	 IBB: nursing. Nursing Interest Based Bargaining Implementation Group.	 http://qheps.health.qld.gov.au/ebb/ib...
17.	Kramer, M. Maguire, P., Brewer, B. et al. 2007. Nurse Manager Support. What is it? Structures 		 and Practices That Pr...
Bibliography•	 Qld Health Business planning framework: a tool for nursing workload management (4th   edition) Resource man...
Role of ward manager
Role of ward manager
Role of ward manager
Role of ward manager
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Role of ward manager

  1. 1. Office of the Chief Nursing Officerwww.health.qld.gov.au/ocno Review of the Nurse Unit Manager Role Final report September 2008
  2. 2. Review of the Nurse Unit Manager RoleFinal reportSeptember 2008Queensland HealthOffice of the Chief Nursing OfficerReview of the Nurse Unit Manager RoleFinal reportSeptember 2008ISBN 978-1-921447-47-1©The State of Queensland 2008.Copyright protects this publication. However the QueenslandGovernment has no objection to this material being reproducedwith acknowledgement, except for commercial purposes.Permission to reproduce for commercial purposes should besought from: Senior Administration Officer Policy Branch Queensland Health PO Box 48 Brisbane 4001Preferred citation: Queensland Government 2008 Review of the Nurse Unit Manager Role Final report September 2008 Queensland Government, BrisbaneAn electronic version of this ddocument is available at: www.health.qld.gov.au/ocno/documents/numreport.pdf
  3. 3. Contents Terms and abbreviations used 3 Executive summary 4 Key issues 6 Recommendations 7 Introducton 12 Methodology 16 Review findings 18 Discussion summary 24 Conclusion 30 Appendicies 31 Acknowledgements I would like to acknowledge Sue Hawes, Principle Project Manager and Helena Harrison, Project Officer from the ‘Take the Lead’ project from the Nursing and Midwifery Office New South Wales Health for their support, guidance and assistance with formatting the Consultation process and sharing their work. Undertaking this project involved many Nurse Unit Managers and ‘acting’ Nurse Unit Managers and I wish to acknowledge their contribution to this project and the time spent meeting me. Kaye Hewson Project Officer Office of the Chief Nursing Officer
  4. 4. Terms and abbreviations used ACIRRT Australian Centre for Industrial Relations, Research and Training ADON Assistant Director of Nursing CN Clinical Nurse DON Director of Nursing EB6 Enterprise Bargaining Six FAMMIS Financial and Materials Management Information System HR Human Resources HPPD Hours Per Patient Day NIBBIG Nurses Interest Based Bargaining Implementation Group. The negotiating team made up of nursing representatives, Queensland Nursing Officials and Human resource branch who coordinate the implementation of EB6 NUM Nurse Unit Manager OCNO Office of the Chief Nursing Officer QH Queensland Health PAD Performance Appraisal Development QNU Queensland Nurses Union
  5. 5. Executive summaryThis report details the findings from the Nurse Unit Manager (NUM) Project undertaken andresourced by the Office of the Chief Nursing Officer (OCNO) from December 2007 - May2008. The project was jointly sponsored by OCNO and the Nursing Interest Based BargainingImplementation Group (NIBBIG).The impetus for the review of the NUM role arose from the recognition that the scope of the NUMrole has increased significantly over the last ten years. The resulting workload significantly impactson recruitment and retention, succession planning and job satisfaction. This is evident by TheWorkforce Recruitment and Retention Report (NIBBIG 2007) where one of the key deliverablesdescribed as a project should be undertaken to redefine the scope of the NUM role. The report alsosuggested strategies be identified to support the position in order to provide career success.The Australian Centre for Industrial Relations, Research and Training identified 15 factorsreferred to as ‘Drivers for Excellence’ for workplaces. The above mentioned report recommendedthat the project indicators for success should include these drivers when reviewing the NUM role.This review sets out to explore the workload and work value of the NUM role in line with theprevious reports recommendations.Information and data from NUM consultation groups and surveys provided informationconsistent with the factors ACIRRT (2003) identified for success in work places. This reportidentifies their perceptions on the scope of the current role, and the barriers and enablers toperforming the role to their own satisfaction which subsequently impacts on the success of theclinical unit and organisation as a whole. Identification of desirable skills and attributes theyregarded as necessary to the role confirmed limited opportunity for learning and developmentinhibit the full potential of this middle management nursing leadership role.The NUMs consultation groups identified a number of key issues in their role. There was a strongdesire to return the role to primarily focusing on clinical leadership. The definition of clinicalleadership provided by the NUMs was ‘driving standards of nursing care and improving patientoutcomes’. However NUMs reported feeling role conflict. Core values of wanting to make adifference to patient care included developing an effective team with the right nursing skill mix.The increase in administration work to maintain the service limits the effectiveness of the NUMto maintain a clinical presence.From the discussion groups in engaging with the NUMs, the general feeling was one of lowmorale, and most felt they were crisis managing from day to day with little opportunity to plan,implement or evaluate their patient service and or their own performance. From the sample NUMpopulation surveyed (n= 154), 37% of NUMs stated they would like to leave the position. 98% feltthey did not have the time to complete their workload adequately. 1 IBB: nursing. Nursing Interest Based Bargaining Implementation Group. http://qheps.health.qld.gov.au/ebb/ibb/Nursing/nibbig.htm 2 Queensland Health Queensland Nurses Union. 2007. Nursing Interest Based Bargaining (NIBB) Project Report. Workforce Recruitment and Retention. http://qheps.health.qld.gov.au/eb6/ibb/Nursing/Recruitment%20and%20Retention%20Final%20Report%2004.07.07.pdf 3 ACCIRRT. 2003. Simply the Best Workplaces in Australia, Working Paper 88, University of Sydney.
  6. 6. The aim of this report is to highlight the vital role of the NUM with the aim of strengthening theenablers that support the work of the Nursing and Midwifery Unit Managers across Queensland.The author suggests that this can be achieved by: • providing clarity around the responsibilities and accountabilities of the NUM role; • enhancing the capabilities of staff in the NUM role; • improving the potential for work life balance within the role of the NUMThis document provides recommendations for NIBBIG to address key issues in the correct role andrefocus the NUM role on clinical leadership which is both an effective application, provides jobsatisfaction and is sustainable.There have been similar bodies of work across several jurisdictions interstate with the same keythemes and issues highlighted for the NUM role. The recommendations are consistent with thesefindings.
  7. 7. Key issuesThe following issues were identified by NUMs who took part in the consultation groups across thestate. These are discussed in more detail in the report: • NUMs workload is perceived to be inequitable to other Grade 7 positions (Clinical Nurse Consultants, Nurse Managers, and Nurse Educators) in terms of responsibilities and accountabilities and workload. • The core responsibility and accountabilities of the NUM role are no longer clear to individuals within the roles. • NUMs want to maintain a clinical focus in order to add value to the role that they play across Queensland Health to improve care and access for patients in the areas they are employed in. The burden of administration tasks means they are finding it increasingly difficult to maintain this presence. • Lack of access to information technology in clinical area inhibits mobility of NUM to maintain clinical presence. • Disparity of upper management styles (nursing and broader) across the state vary from little contact to total control resulting in NUMs being held to account with no ability to make decisions or strategically influence. • Where there is no strong professional relationship with the line manager NUMs self report no coaching to develop advanced critical thinking and problem solving skills. • Insufficient collaboration in decision making between financial managers and NUMs in budget allocation when NUMS are held accountable for insufficient resources. This is a reactive management rather than proactive management style. • In the absence of targeted training for NUMs Queensland Health current data systems are not fully utilised by this group as a tool for efficiency in the management of people, patients and resources. • There is no current consistent orientation into the role. • Development into the role currently occurs via an adhoc process with no structured process of assessing and developing the skills and competencies for individuals to reach their full potential in the role. • No formal medium exists to access suitably trained mentors within Queensland Health to grow future nurse leaders and assist the NUM to face the challenges of contemporary nursing practice and patient care. • NUMs self report feeling professionally isolated from their peers through recurrent health system restructuring and organisation. • There is no defined succession planning mechanism to enable Clinical Nurses to access suitable courses and professional development activities to develop into future NUM roles. • The role is not perceived to be attractive to Clinical Nurses to ‘act into’ the position as they are often financially disadvantaged when they are not working shift work. • NUMs self report that they carry a heavy workload. This is a disincentive to succession planning and individual NUMs feel powerless to address this.
  8. 8. Recommendations for NUM roleFunding will need to be sourced for the implementation of the following recommendationsaddressing the key issues identified above:Recommendation 1:That Queensland Health addresses the inequity of the work level standards of the Grade 7 roles by: • Reviewing the Nursing and Midwifery Classification Structure HR Policy B74 that define the core purpose of the position. • Reviewing the descriptors for work span, impact of the position, the diversity, integration and complexity of work performed, autonomy and typical responsibilities found at the level are agreed upon by all stakeholders. • Defining and developing a career pathway for each of the four streams of Grade 7: clinical, management, education and research across the state.Recommendation 2:2.0 That the role of the Nurse Unit Manager is evaluated through a Job evaluation System5 which is a method of assessing the work value of the role to address the inequity in current workloads between NUMs. The work value will then determine a difference within the NUM classification level. Work level differentiation is determined by the following variables: • Full time Equivalent numbers versus headcount of total number of staff. • Staff mix • Reporting structures • Support networks and infrastructures • Hours of operation of service • Ward unit geography (within organisation or isolated) • Ward Unit complexity, acuity of patient presentation and unpredictability.Bands within the grade 7 are assigned according to allocated level of responsibility. Threebandswithin the NUM role should reflect the degree of responsibility and work value of individualNUMs contribute to resolving the inequity within the role that currently exists.2.1 That job classification analysis provides definitions of skills, competencies and formal qualifications to fulfil the contemporary role of the NUM.2.2 That the core business and responsibilities of the NUM is defined and agreed upon and form a platform upon which all role descriptions are based in the future. 4Queensland Health. 2008. Nursing and Midwifery Classification Structure HR Policy B7 http://www.health.qld.gov.au/hrpolicies/resourcing/b_7.pdf 5 Mercer Human Resource Group. 2000. Nurse Unit Manager Classification Review
  9. 9. Recommendation 3:That by reviewing the role of the NUM it is recognised that this will have an impact on othergrades within the Nursing and Midwifery Classification Structure and that further considerationshould be given to developing career pathways. Within the classification structure otherjurisdictions such as Victoria and the Australian Capitol Territory (ACT) have established rolesfor the four streams of clinical, management, education and research which articulate into careerpathways through the defined stream. For example the Associate NUM role aligns with the NUMrole, the Clinical Nurse Specialist aligns with the Clinical Nurse Consultant.Risk to QH of non implementation of recommendations 1-3: • Current difficulties of recruiting into NUM role and retention of experienced staff in NUM roles will reach critical levels. • Attrition rates from NUM role will continue as other Grade 7 roles appear more attractive in comparison.Recommendation 4:That the core responsibility of the NUM role will be recognised and supported as clinicalleadership. This is enabled by the following: • NUM needs to support evolving models of care by being accessible, visible and leading the clinical coordination of clinical care including nursing, medical and allied health members to providing the service and good patient outcomes. • The NUMs role will be standardised across the state to not be included into the nursing Hours Per Patient Day (HPPD). The Business Planning Framework (BPF) methodology has enabled this recommendation for some time and the revised BPF will further support this recommendation. Clinical leadership is enabled by flexibility within the role to drive the service model and workforce mix. • NUM receive (formal and informal) constructive supervision as part of a NUMs PAD by their line manger via coaching to confidently problem solve and think critically.Risk to QH of not implementing Recommendation 4 • That if not utilised effectively the potential of this highly skilled nurse leader to affect good patient outcomes and quality of service is not realised when evidence based practice supports this recommendation.Recommendation 5:That identification of administration tasks that do not require the specialist skill set of theNUM are assigned to an administration officer. It is expected that the above mentionedrecommendations will result in resource allocation to support nurse leaders with administrationtasks.
  10. 10. Recommendation 6: – Identify key issuesThat the NUMs clinical leadership role is supported by mobile technological support for greateraccess to information management allowing them to analyse and support decision making whilstmaintaining a clinical presence. • Handheld Blackberry or devices or similar service the needs of the Rural and remote NUM to align their phone and internet access with their on call needs. • Notebooks (CV5) or similar for larger metropolitan and regional organisations.As supported by the E- Nursing strategy (QH 2008, Goal 3) as a recommendation for effectivepractice.Risk to QH of not implementing recommendations 5 and 6: • That Nurse Unit Managers continue to be overwhelmed by administration tasks which do not require the unique skill set of the NUM. • That unavailability of Information technology (IT) that supports contemporary nurse practices adds to inefficient work practices, data collection and duplication of information.Recommendation 7:That preparation for aspiring NUMs is standardised and consistently applied across theorganisation by: • Provision of a comprehensive orientation and ongoing training in QH systems as a prerequisite to commencing work as a NUM. The recommended time period is supported by the BPF as up to 11 days. • A Manager Orientation/Resource Guide developed to assist orientation into the role. Helpful information encompassing human resource, financial (includes targeted training in BPF); material and clinical governance and information management would be included. • Every new NUM linked to a formal mentoring program for a period of six months to develop leadership and people management skills. Development of a Mentoring Framework across Queensland with supported access through IT technology to reach rural and remote NUMS should be included. • Access to the Clinicians Development Education Service (CDES) (partnership between University of Queensland, Med-E-Serv and QH) for CNs and NUMs to acquire the essential skill set for the NUM role available on line. Financial support and backfill to complete and build up a portfolio of credits to achieve baseline knowledge of management and business processes through to post raduate qualifications needs to be forthcoming. g
  11. 11. • Registered Nurses Grade 5 and 6 identified through Performance Assessment and Development Process (PAD) as interested in relieving the NUM for periods of leave or secondment being given the opportunity for work shadowing and formal training into the role of the NUM.Risk to QH of not implementing recommendation 7: • That the lack of succession planning and support to develop into the NUM role is a disincentive for recruitment. • Sustainability of leadership development for the professional of the future not realised. • That NUMs will continue to have only base qualifications of Registered Nurse training or Bachelor of Nursing for role which requires further development and enhanced skill set to maximise potential for effective patient outcomes and service delivery.The following recommendations do not need additional funding and can be implemented at alocal level immediatelyRecommendation 8:That formal network of discussion groups are enabled by the organisation so NUMS can meetregularly for peer supervision, support and problem solving for example. NUMS working inisolation videoconference monthly with regional centre NUMs and are supported to visit regionalor metropolitan facilities twice a year.Risk to QH of not implementing recommendation 8 • That NUMs remain in isolation professionally inhibiting their ability to develop support networks and act collectively to provide proactive leadership for the health care facility.Recommendation 9:That the NUMs are able to: • Work self managed hours for work life balance and family friendly rostering including eight or nine day fortnights. • Enter into job share work practices. This is especially attractive for NUMs nearing the end of nursing careers, returning from maternity leave and with family and study commitments.10
  12. 12. Risk to QH of not implementing recommendation 9: • That the inflexibility of work practices makes a significant impact on work life balance of NUM and creates disincentive to recruit into NUM role. • Not catering to mature age nurses needs increases the skill drain from the nursing workforce.This recommendation has implications for EB7Recommendation 10:Single on call allowance should be changed to an hourly rate to recognise the on call workloadof Rural and Remote NUMs.Risk to QH of not implementing recommendation 10:That non-recognition of on call workload acts as a disincentive to recruitment and retention ofRural and Remote NUMs. This report maps out the breadth of the role of the NUM across Queensland. This is articulated through consultation with NUMs from rural, regional and metropolitan health service locations. Currently there is great variability in the role. From the consultation process, returning the core function to clinical leadership is essential. The recommendations are a way forward to enable the role to achieve this focus in the future. 11
  13. 13. 2.0 Introduction2.1 Background to projectThis report details the outcomes of a six month project conducted and funded by the Office ofthe Chief Nursing Officer reviewing the role of the NUM (December 2007 – May 2008) to makerecommendations on the future scope of the role.The Nurses (Queensland Health) Certified Agreement (EB6) identified the development andimplementation of a nursing recruitment strategy as one of the five priority areas. One of the keydeliverable from the Workforce Recruitment and Retention Report 2007 was for QH to undertakea project to define the current scope of the NUM role and provide strategies to support theposition and ensure career success.The Nursing and Midwifery Classification Structure (HR Policy B7)4 defines the Nurse UnitManager as a registered nurse who is accountable at an advanced practice level for thecoordination of clinical practice and the provision of human and material resources in a specificpatient/client area and who: • has ability to lead a nursing team in multi disciplinary environment utilising the principles of contemporary human, material and financial resource management; • demonstrates sound knowledge of contemporary nursing practice and theory; • participates directly or indirectly in the delivery of clinical care to groups/individuals/ groups; • ensures clinical practice is evidence based to facilitate positive patient outcomes; and • has sound knowledge and the ability to apply relevant legislation, guidelines and standards.’The Workforce Recruitment and Retention Report2 (NIBBIG 2007) identifies the NUM role as atrisk of work overload and loss of clarity around the perceived expectation of the role by theNUMS themselves and others in the organisation. Consequently, in comparison to other Grade7 roles which have more defined areas of responsibility, it now appears a less attractive role forcareer progression.This subsequent report recognises the impact the NUM role has on the workforce andorganisation. Recent changes in the health care service have resulted in a demand for efficiencyand patient outcomes. In response to this, restructuring has resulted in expanded areas ofresponsibility for the NUM requiring a broad range of skills and an increased work load. It is 2 Queensland Health Queensland Nurses Union.2007. Nursing Interest Based Bargaining (NIBB) Project Report. Workforce Recruitment and Retention. http://qheps.health.qld.gov.au/eb6/ibb/Nursing/Recruitment%20and%20Retention%20Final%20Report%2004.07.07.pdf 4 Queensland Health. 2008. Nursing and Midwifery Classification Structure HR Policy B7. http://www.health.qld.goau/hrpolicies/resourcing/b_7.pdf12
  14. 14. widely acknowledged Queensland Health2 is experiencing difficulty in recruiting and retainingNUMs when their job satisfaction is reported as very low. Clinical nurses do not embrace theopportunity to ‘act up’ in the role for professional development due to their perception of therole.The ACIRRT (2003)3 identified 15 factors which they called ‘Drivers for Successful Workplaces’.The Recruitment and Retention Project Report (2007)2 recommended the 15 key drivers ofsuccessful workplaces should be included as project indicators for the NUM review. These include: • Quality working relationships – how people relate to each other in the workplace including friends, colleague and co-workers in supporting each other and getting the job done. • Workplace leadership – the focus being on leadership and energy not management and administration. • Having a say – participating in decision making which affects workplace business. • Clear values – people share the same values and attitude to work. • Pay and conditions – level of income and working environment needs are met to a standard acceptable to workers. • Getting feedback – always knowing what people think of each other, their contribution and success to the workplace. Individual performance feedback. • Learning – being able to learn on the job, acquire skills and knowledge and develop an understanding of the whole work place. • Autonomy and uniqueness – the capacity of the organisation to tolerate and encourage individuals to be creative and different which develop excellent workplaces. • Sense of ownership and identity – being seen to be different through and special, taking pride in workplace, knowing your business well. • Passion – having energy and commitment to the workplace. • Having fun – workplaces which are psychologically secure so people may relax with each other and enjoy social interaction. • Community and connections – being part of the local community, feeling as though the workplace is a valuable to the community. 2 Queensland Health Queensland Nurses Union. 2007. Nursing Interest Based Bargaining (NIBB) Project Report. Workforce Recruitment and Retention. http://qheps.health.qld.gov.au/eb6/ibb/Nursing/Recruitment%20and%20Retention%20Final%20Report%2004.07.07.pdf ACCIRRT. 2003. Simply the Best Workplaces in Australia, Working Paper 88, University of Sydney. 3 13
  15. 15. The Queensland Health report ‘better workplaces’ Staff Opinion Survey (2007)6 also recognisespsychological factors effect staff performance so that staff will be happier when experiencing orhaving access to a better quality of life at work, improved workplace morale, adequate supervisorsupport, be participative in decision making, professional growth, develop role clarity andestablish peer support.This document provides a narrative around the findings of a project which aimed to explore anddescribe the current context of the NUM role within the clinical ward/unit. It maps the skillsand attributes NUMs perceive they require to fulfil the role and also identifies the enablers andbarriers to maximise the effectiveness of the role and for personal satisfaction.Identification of key issues for the NUM role informs the recommendations that have beenproposed in this report. The implementation of these recommendations will ensure the roleof the NUM is reinvigorated and centred on clinical leadership. It would further ensure that afoundation is put in place to sustain the NUM role for the future.2.2 Project overviewThe project was conducted in three phasesPhase one: • Development of a framework for the project • Literature review • State wide and interstate exploration of research completed or in progress around the NUM role.Phase two: • Development of questionnaire • Consultation groups planned and conductedPhase three: • Draft report circulated to relevant stakeholders • Final report including findings and recommendations 6 University of Southern Queensland. 2007. Report of ‘better workplaces’ Queensland Health Staff Opinion Survey. http://qheps.health.qld.gov.au/central/workforce/casu_final_wct.pdf14
  16. 16. 2.3 Project limitationsThe project is relatively modest in its aims and scope.Data to support the definitive number of NUMs in positions in Queensland and vacancy rateswas hard to determine. Lattice does not provide information with descriptor of the nursingclassification Grade 7 allowing for differentiation between the roles at this level.The new Queensland Health Human Resource data base system Panorama has the capability toprovide this information but as yet it is not available. Based on district information supplied itis estimated there are approximately 600 NUMs in our nursing workforce. Vacancies can only bedetermined as L4 at 102.9FTE across all NO4 and above positions with a 3.0FTE critical. Criticalis determined as unfilled, temporarily filled and unbackfiled long term leave.It is recognised there is variability on the application of the middle manager classification.Some facilities have Clinical Nurse Consultants that manage a clinical cost centre and thereforealthough the project is limited to NUMs the same issues may apply.It is also recognised within the methodology that the collection and analysis of statisticalinformation was not the intent of the questionnaire but rather as a mechanism to engage theNUMs and facilitate discussion around their perceptions of the role. However some interestingthemes and trends emerged which was consistent with the literature review and the researchproject ‘Take the Lead, Strengthening the role of the Nursing and Midwifery Unit Managers acrossNew South Wales’ (Hawes 2008)8. Convergence of themes in the data and through these mediumsstrengthens the overall findings. 8 Hawes, S.2008. ‘Take the Lead’. Strengthening the role of the Nursing Midwifery Unit Managers across NSW. New South Wales, Nursing Midwifery Office, NSW Health. http://www.health.nsw.gov.au/nursing/pdf/nmforum_take_lead_pres_apr08.pdf 15
  17. 17. 3.0 Methodology1. Literature review of international, inter state and state wide research and peer reviewed articles on middle management nursing leadership roles.2. A review of Position descriptions for the NUM role interstate and state wide.3. A survey of NUMs acting and permanently appointed to role was conducted.4. Consultation groups made up of acting and permanently appointed NUMS.5. Consultation with stakeholders in OCNO, Corporate Office Human Resource representative and Queensland Nurses Union (QNU).6. A review of current education/professional development opportunities for NUM within Queensland Health.3.1 Literature ReviewThe aim of the literature review was to identify research and relevant information on the NurseUnit Manager role, as well as matters relating to recruitment and retention, and job satisfaction.The literature review was developed through database searches using search engines andacademic databases such as the QHEPS, Google, Proquest, Informit, and EBSCO to identify arange of online journals, policy documents, enterprise bargaining agreements and governmentreports. The literature review included international and Australian academic literature,government reports and research data. This provided valuable information into the value of theNUM role in providing leadership, the development of skills and attributes that are considerednecessary for the role and the responsibility attached by the role.3.2 Information Collection3.2.1 SurveysThe purpose of the questionnaire was to develop a broad understanding of the attitudes anddifficulties that NUMs currently experience in their workplace and asked to signal what changeswould enhance their ability to do the role. The questions were formulated in consultation withsenior nursing colleagues. Principally the questionnaire was used to elicit engagement with theNUMS rather than collect a large range of data. However some interesting data resulted.16
  18. 18. 3.2.2 Consultation Groups17 Groups consisting of 5-15 acting and permanently appointed NUMs met across the state andtook part in 2-3 hour workshops. Consultations groups involved over 160 NUMS in total.Sites visited included Cairns Base, Townsville, Mt Isa, Toowoomba (Included Toowoomba Baseand Ballie Henderson Hospitals), Dalby, Redlands, Logan, The Gold Coast, Robina, The SunshineCoast, Redcliffe, The Prince Charles Hospital, The Royal Brisbane and Women’s Hospital and thePrincess Alexandra Hospital. In Cairns NUMs travelled from Atherton and Mareeba and Yarrabahto be part of a consultation group. In Townsville a NUM travelled from Palm Island. In DalbyNUMs travelled from Miles and Chinchilla to be part of the consultation group. Within Districtsrepresentatives came from community health and schools and mental health was representedcommunity wise and by specific hospital. Midwifery Nurse Unit Managers also took part andattended from those sites which offered midwifery services.Engaging NUMS was viewed as essential to the process of successful review. Consistentinformation was gathered through this approach. NUMS were very receptive to the opportunity tomeet and contribute to the project. Vignettes from NUMS ‘There is light at the end of the tunnel but a the moment it is a train coming’ ‘It seems like the paperwork is taking over’ ‘When I first started I only found out how to do things by making mistakes’ ‘I didn’t have choice I was the last Clinical Nurse on the ward’ ‘The buck stops with the NUM, hit from below, hit from above!’ 17
  19. 19. 4.0 Review findings4.1 Themes emerging from the consultation groupsThe key themes which emerged from questionnaires and consultation groups are structured intothree key areas which support the end discussion which centred on what an ideal role will looklike: • The breadth of the current role with regard to responsibilities, accountabilities and reporting. • Identifying skills and attributes seen as essential to the role. • Barriers and enablers to performing the role to the NUMS satisfaction and for an effective and efficient clinical service.4.2 Current RoleIn exploring and describing the current context of the NUM role within the clinical ward/unit thisdocument provides a narrative around the findings.The following areas of responsibility are broadly summarized as follows:Leadership of Clinical area • Patient flow • Standard of care • Driver of model of care • Patient and family advocate • Discharge planningGeneral management of • Human resource and staff • Budgeting • Unit equipment and maintenance • Communicating with othersClinical governance • Occupational health and safety • Quality projects, research • Audits • Complaints and incident investigation • Incident management and monitoring • Risk and hazard identification • AccreditationLeadership • Role modelling behaviour18
  20. 20. • Leading the team • Professional development • Change managementOther (mainly rural and remote but not limited to these facilities) • Travel, accommodation arrangements for staff/patients • Escorting patients via ambulance • Overseeing vehicle maintenance and control • Counselling of staff • On-call • Public relations • X-ray operator(See appendix 1 for full description from NUM groups and of what NUMs perceive their role entails)4.3 Skills and AttributesSkills are defined as things learnt or possessed to enable them to effectively manage the job, andattributes are characteristics which they possess which make them suited to the position.Skills and attributes include but are not limited to: Skills Attributes Problem solving Trustworthy, honest Critical thinking Compassionate Leadership and vision Fair/balanced Political astuteness Energetic/motivated Interpersonal skills Resilient Advanced communication Patient/tolerant Active listening Calm IT/Data management Commonsense Financial management Advocate for staff and patients Clinical credibility Sense of humour Conflict resolution Discrete (See Appendix 2 for NUM brainstorm of skills and attributes)4.4 Barriers and Enablers4.4.1 Barriers • Barriers are described as things which inhibit the ability of the individual NUM to perform the job to the level of their own satisfaction. These include but are not limited to: • Lack of understanding and expectation of the role by: – Self – Organisation (includes nursing staff, medical, allied health and executive management team) 19
  21. 21. • Inconsistencies in the role across QH • Lack of staff: – Recruitment processes are long and time consuming – Shortage of and temporary positions. – Skill mix limiting opportunity for succession planing/requiring constant presence in clinical unit of Clinical Nurses and NUM. – NUMs counted into clinical hours. • Lack of resources and ability to influence budget. • QH processes for rostering, payroll, financial management, reporting. • Professional development within role: – Limited to adhoc courses/workshops. – Tertiary study within own time(See appendix 3 for NUM brainstorm of barriers).4.4.2 EnablersEnablers are defined as factors which enhance the ability of the NUM to perform their job to theirown satisfaction. These include but are not limited to the following: • Support and respect from nursing executive and senior management. • Support from own team and being part of a team. • Support and opportunity to meet peers. • Staffing – Adequate staffing – Adequate skill mix for acuity of patients • Communication – Access to information – Opportunity to contribute an opinion • Structured education and professional development for role with allocated time – People management – Financial management – Mentoring relationships • Resources – Budget – Equipment – Support roles (administration, education, operations staff)(See appendix 4 for brainstorm of perceived Enablers from NUM consultation groups).20
  22. 22. 4.5 Questionnaire resultsQuestionnaires were completed at a return rate of 96% (n= 154).Of the 154 responses, 32 (21%) indicated they were in ‘acting’ NUM roles. 12 of this cohortindicated they would not apply for the position should it be advertised and 20 indicated theywould apply.Graph 1: Respondents in ‘acting’ positions were asked would they apply for the position if theposition became vacant. n=32 Acting NUM’s responses to whether they would apply for the position. Yes No 38% 62%Three people had been in ‘acting’ positions for 3 years or more. Of this small sample, twoindicated they would apply for the position should it become vacant.34% of the “acting” NUM sample indicated they had taken on the role due to their perceptionthere was no one else, however approximately 46% of this cohort considered that the reason fortaking the position was also an opportunity for professional development purposes. For a smallsample those who had taken on the position for professional development felt hindered in thisbecause they were expected to ‘care take’ in the role and not develop the area per se.Reasons for not applying for permanent NUM positions were working under constant pressureand feeling inadequately prepared for the role. Effective orientation and supportive professionalrelationships from the CNCs and Clinical Nurse Teachers were stated as desirable but currentlynot effective.Of the 122 permanently appointed NUMs 44 (36%) stated they frequently considered leavingthe position. Whereas 64% indicated they would not consider leaving. These figures are slightlyhigher than the workforce survey (2007) figure of 31.8% of employees who consider leavingQueensland Health. 21
  23. 23. Graph 2: The respondent sample was asked to list number of years in the NUM role. 25 20 15 Yes respondents to leaving to No respondents to leaving 10 5 0 12 months 1-2 years 3-5 years 6-10 years 10 yearsSome of the reasons given for considering leaving included a perceived lack of executivemanagement (nursing and district) constructive supervision combined with not being givendecision making authority and directives to achieve deliverables without a commensurateresource allocation. There was ambiguity about role expectation and the scope of the role thatwere factors for other ‘yes’ respondents. The NUMs also indicated they perceived a higher levelresponsibility and accountability than other grade 7 positions specifically the CNC and that theirpay did not reflect this.Graph 3: The respondents were asked what they considered the barriers to performing the role totheir own satisfaction. 100% 80% 60% Agreed 98% 40% 54% 54% 45% 20% 37% 0% Lack of time Lack of Workforce Lack of Lack of dedicated shortages support training administration time‘Lack of time’ to complete workload had 98% response rate as a barrier to performing the role tothe standard NUMs desire.When asked what changes would the NUMs require to consider staying or enhancing theirability to do the role: 57.3% stated clinical support, 53% business support, 53% informationmanagement, 47% human resource support, and 31.9% quality and safety support. Additionalcomments included a need for Work- Life balance strategies and role clarity. Administrationsupport was also stated as highly desirable.22
  24. 24. NUMs were asked to indicate what was the highest level of education they had obtained, andif they had found that education beneficial. Most had attended a variety of workshops andshort courses but few indicated whether they found them useful. The majority of respondentswho had completed the Graduate Certificate in Health Management found it useful.Limitations in the questionnaire design describing the exact educational requirements withinthis middle management nursing group prevented further analysis. NUM Vignettes ‘You won’t get me to stay!’ ‘To be heard and listened to!’ ‘If you look like you’re coping you’re right!’ ‘What has stopped me leaving is a dynamic and supportive Nursing director!’ ‘More autonomy and less blaming’ 23
  25. 25. Discussion summaryIt was evident through comments made in consultation groups that for the majority of theparticipants, morale and job satisfaction were very low.Current roleThe NUMS felt conflicted in their role as there are no clear delineation between management ofa cost centre and leading a clinical ward/unit. The NUMs have taken on roles and responsibilitiesthey consider to be outside of their role description. However the culture of the organisation issuch that they feel they are unable to say no without being made to feel they are not up to thejob9. ‘Role ambiguity’10 causes confusion as to where the main focus of the role should be. Roleclarity is therefore clearly desirable8,9.Administration duties reportedly consume most of their time. NUMs are a finite highly skilledresource and would be more efficiently utilised to refocus the role if the clinical leadership wasfocussed. All NUMs identified this as the desired focus of the position. All groups identifiedadditional administration support as highly desirable to support refocusing their role on clinicalleadership. This is further supported by the recommendations arising from the NIBBIG Work LifeBalance report 200712.Paliadelis, Cruickshank and Sheridan (2007)13 in a study of 20 NUMs in Australia found they werenot educated to cope with their increased responsibility around administrative and managerialrequirements. Instead NUMs feel they are unable to support clinical outcomes and staffsufficiently10,13. NUMs describe themselves as ‘drowning in paper work’ as work stacks up andthere are ever increasing competing priorities.NUMs who have seen their role expand in responsibility and undergone several name changesover the last ten years regret the loss of their clinical expertise and patient contact. Other similargrade roles appear more attractive to the NUM. The Clinical Nurse Consultant, as an example isa clinical specialist who works across units providing clinical expertise and guidance with nohuman resource, financial or material management responsibilities4. 4 Queensland Health. 2008. Nursing and Midwifery Classification Structure IRM 4.8-2. http://www.health.qld.gov.au/hrpolicies/resourcing/b_7.pdf 8 Hawes, S.2008. ‘Take the Lead’. Strengthening the role of the Nursing and Midwifery Unit Managers across NSW. New South Wales, Nursing and Midwifery Office, NSW Health. http://www.health.nsw.gov.au/nursing/pdf/nmforum_take_lead_pres_apr08.pdf 9 Duffield, C., Kearin, M., Johnston, J., and Leonard.2007. The impact of hospital structure and restructuring on the nursing workforce. Australian Journal of Advanced Nursing, 24(3): 42-46. 10 Stanley, D. 2006. Role conflict: leaders and managers. Nursing Management, 13(5): 31-37. 12 Queensland Health and Queensland Nurses Union. 2007. Nursing Interest Based Bargaining (NIBB) Project report. Work Life Balance http://www.health.qld.gov.au/eb/nursing_ibb/work_life_bal.pdf 13 Paliadelis, P., Cruickshrank, M. and Sheridan, A. 2007. Caring for each other: how do nurse managers ‘manage’ their role? Journal of Nursing Management, 15: 830-837.24
  26. 26. There is a strong argument for optimising the role of the NUM by making better use of the skillsof the NUM to affect patient care. This can be achieved by maintaining a clinical presence onthe ward. Due to the dual roles of management and leadership it is not possible for the NUMto remain a clinical expert however a clinical supervision role is highly desirable. The NUMcurrently provides a consistent presence on the ward/unit when the majority of the work forcework shift work and many are part-time. Trends in the nursing workforce such as an agingworkforce and desire for work life balance in the labour market suggest this will continue.The benefits to the clinical unit/ward are the NUM provides a standard of professional practiceand improved patient care by role modelling behaviours and improving communication acrosspatient care. This is achieved by being the consistent presence on the ward. Managing stressfulsituations and providing support to staff improves retention and job satisfaction for staff14. TheNUM remains credible to staff by working alongside them and earning their trust. Redefiningroles and matching them against skills can improve patient care, reduce waste, and improveworking lives and reducing mistakes and errors15.Transformational leadership qualities are associated with effective change management,empowering work conditions, influencing staff and policy and job satisfaction. There is growingevidence from research state wide, interstate and internationally into the positive impact thatmiddle management nursing leadership roles have on improving patient outcomes and serviceprovision16,17. In one Queensland hospital, a new model of care had been adopted as the resultof a two year ‘Professional Practice Partnerships’ Skill mix Research Project18. Within this modelthe NUM is required to remain as a complementary figure driving clinical standards of care androle modelling behaviours until 12:30pm daily. The evaluation shows proven patient outcomesincluding reduced patient falls, pressure areas and medication errors. Scheduling of meetingsand administration tasks are left for the afternoon when clinical activity is reduced and doublestaffing of nurses occurs. NUMs involved report improved job satisfaction through the ability toprovide clinical leadership with organisational support. 14 Chiarella, M. 2007. Redesigning models of patient care delivery and organisation: building collegial generosity in response to workplace challenges. Australian Health Review, 31(S1): S109-s115. NHS Modernisation Agency. 2004. 10 High Impact Changes for service Improvement and Delivery. A guide for 15 NHS leaders. 16 Newman, S. 2005. The impact of health reform on nurse managers and their management of nursing services: a study of the Australian Context. Paper presented at 6th Annual Interdisciplinary Research Conference, Trinity College, Dublin. 17 Kramer, M. Maguire, P., Brewer, B. et al .2007. Nurse Manager Support. What is it? Structures and Practices That Promote it. Nursing Administration Quarterly 31, (4), 325-340. 18 Jones, J., Lowe, M., Burns, C. Donaldson, P., Abbey, J. Abbey, B. 2008. Practice Partnership Model: An innovative approach for nursing at The Prince Charles Hospital (TPCH). Final Report of the Skillmix Research Project. QH and QUT. 25
  27. 27. The opportunity to network and derive support from meeting their peers formally was providedthrough the consultation groups. NUMs all expressed their regret of not having this opportunityregularly where they had experienced it in the past before restructuring into departmentmeetings. In rural and remote areas all of these issues are compounded by the isolation of therole from peer support.For the rural and remote NUM the transient nature of the workforce means they have the addedpressure of being on call and may be the only person able to perform advanced clinical skillssuch as x-ray taking. Remuneration provided hourly for on call hours allocated would recognisethe significant percentage of time rural and remote NUMs spend on call and would reinforce thevalue of the NUM role within the rural and remote health care system.NUMs generally feel undervalued by the organisation. Research by Day, Minichiello and Madison(2006,p517)19 reveals that low morale is linked to intrinsic factors such as ‘professional worthand respect, opportunity and skill development, work group relationships and patient care’and extrinsic factors such as ‘organisational structures, operational issues, leadership traits andmanagement styles, communication and staffing’. The NUM role is affected by these factors andequally their job satisfaction impacts on the rest of the nursing staff under their leadership.Similar issues have been identified in other jurisdictions who have implemented solutions in anumber of ways. The Australian Capital Territory, Victoria and Western Australia have providedclear career pathways within the nursing classification structure across clinical, managementeducation and research. This has implications for the adjacent nursing grades within theclassification structure before and after but provides a direct career pathway for nurses enteringthe clinical arena and allowing direction through performance appraisals and professionaldevelopment.There is a strong argument from the NUMs themselves in that this allows the roles to line upto support each other rather than working independently of each other across the organisation.Having direction will increase retention amongst all staff especially the generation ‘Y’ that thriveson opportunity and strong leadership20.NUMs self reported that there is inequity of work value within the role. The Mercer Group 20035has undertaken a Job Classification Evaluation of the NUM role in both Victoria and NorthernTerritory with a resulting banding of streams around the key work value descriptors of full timeequivalent (FTE) numbers (or head count), skill mix, reporting structures, support networks andinfrastructure, hours of operation, ward unit geography, ward unit type and ward unit complexityand unpredictability. Remuneration is awarded in band for level of the work value determined byexpertise, judgement and accountability. Applying work values addresses the inequity 5 Mercer Human Resource Group. 2000. Nurse Unit Manager Classification Review. 19 Day, G.E., Minichiello, V. and Madison, J. 2006. Nursing Morale: what does the literature reveal? Australian Health Review, 30 (4), 516-524. 20 Walker, K. 2007. Fast-track for fast times: Catching and keeping Generation Y in the nursing workforce. Contemporary Nurse, 24(2): 147-158.26
  28. 28. experienced within the NUM role across Queensland Health currently where a NUM who has asmall staff and works office hours is payed the same as the NUM providing leadership to a largeacute care unit with a large volume of staff.(Recommendations 1, 2 3, 4, 5, 8, 10)Skills and AttributesCurrently Queensland Health role descriptions state no more than base line qualifications,Bachelor of Nursing or Registered Nurse Training as mandatory. A Job Evaluation Analysis5 ofthe role would provide definitions of skills, competencies and qualifications seen as desirable forthe contemporary NUM role.In identifying skills and attributes felt necessary for the role the NUMs frequently expressedfrustration over the limited orientation provided for the role. Negotiating the complex QueenslandHealth system, especially HR and FAMMIS, and receiving inconsistent advice from officers fromthese departments means a learning process of trial and error. Changes to the systems would bewelcome but previous experience with new data systems for rostering and patient acuity meanNUMs view them with suspicion and dread.NUMs feel ineffective in fighting for resources as many identified they did not have theknowledge to manage the business side of the ward/unit. The Business planning frameworkwas seen as a useful tool for some but many who had received no real training into the processwere left feeling impotent in trying to fight for resources when invited to participate in budgetworkups.The NUMS identified that leadership workshops and courses were helpful but translating andsustaining this in the workplace was difficult. The literature supports the correlation betweeneffective leadership and high quality nursing care (Jarman 2007)21. A mentoring process wouldsupport the personal growth of the NUM and provide a support network22. Every consultationgroup expressed the view that lack of mentoring relationships limited their potential for growthwithin the role. Mentoring has also been identified as important to developing future nurseleaders in facilitating new learning experiences and guiding career decisions23.Lack of articulated or supported education in the role also affects succession planning. NUMssuggested work shadowing and a formal course provided by their organisation would assist thisprocess. The literature supports this approach. Wolf, Bradle, and Greenhouse24 found through theirresearch Nurse Unit Managers frequently feel unprepared for the challenges within the role. 5 Mercer Human Resource Group. 2000. Nurse Unit Manager Classification Review. 21 Jarman, H. 2007. Consultant nurses as clinical leaders. Nursing Management, 14(3): 22-26. 22 Gallo, K. 2007. The New Nurse Manager: A Leadership Development Program Paves the Road to Success. Nurse Leader, 5(5): 28-32. 23 Redman, R.W. 2006. Leadership Succession Planning. The Journal of Nursing Administration, 36(6): 292-297. Wolf, G.A., Bradle, J. Greenhouse, P. 2006. Investment in the Future. A 3-Level Approach for developing the 24 Health care Leaders of Tomorrow. The Journal of Nursing Administration, 36(6): 331-336. 27
  29. 29. Strategies need to be put in place to ensure NUMs develop the business knowledge and otheressential skills for the role25.One potential solution for NUM could be through utilisation of the Clinicians DevelopmentEducation Service offered by the partnership between the University of Queensland, Med-E-Servand Queensland Health will offer Quality and Safety, Education and Workforce Development,Health Services Management and Innovation and Change modules for health professionals toaccess online. There are no semesters or time limits set on individuals and the student can buildup to a full credit for post graduate qualifications or sample subjects which are of interest. Accessto such programs for NUMs will provide access, opportunity and the potential for personalgrowth within the role.(Recommendation 7)Barriers and EnablersThe nature of the workforce means the NUM has taken on a nurturing role caring for thegeneral welfare of all the nursing staff in their area. NUMs felt the generation Y expectationsof the workforce forced the need for a nurturing role; words used to describe themselves were‘counsellor’, ‘agony aunt’, ‘mother figure’. They found this rewarding but time consuming and felttorn with competing priorities. Some NUMs shared offices and consequently found maintainingconfidentiality during performance management challenging.Critical thinking and problem solving were identified as desirable skills for the NUM by thegroups. Yet the NUMs often complained of lack of constructive supervision by ADONs, DONs16.This was also true of the District Managers in the more regional and remote areas. Directcorrelation between effective supervisor support and coaching and the positive attitude ofNUMs to their role. It was very obvious when this level of support was afforded to the NUMby the positiveness of their attitude and belief in themselves. NUMs who had been coached bythe ADONs felt empowered to make decisions and contribute to budget and other decisions.Organisational support has the proven benefit of developing transformational leader behaviourand ensuring greater communication with supervisors26.Succession planning was identified as extremely difficult to achieve in the current environment.NUMs felt powerless to influence this due to the workload. It was identified in every group aclinical nurse could earn more money with shift work penalties and working fewer hours than thebusiness hours the NUM worked. NUMs report arriving early and leaving late. Time to orientateand develop CNs into the acting NUM role was seen as lacking. NUMs voiced frustration overdealing with a workload left by acting NUM who backfiled them whilst they were on leave. 16 Newman, S. 2005. The impact of health reform on nurse managers and their management of nursing services: a study of the Australian Context. Paper presented at 6th Annual Interdisciplinary Research Conference, Trinity College, Dublin. 25 Kleinams, C.S. 2003. Leadership Roles, Competencies, and Education. How Prepared Are Our Nurse Managers? Journal of Nurse Administration, 33(9): 451-455. 26 Laschinger, H. Wong, C. 2007. A profile of the Structure and Impact of Nursing Management in Canadian Hospitals. Final Report for CHSRF Open Grants Competition project # RC1-0964-06.28
  30. 30. NUMs who had worked in other states/territories suggested an Associate NUM role which wouldassist with both workload and succession planning. Currently the ‘Path of Chance’27 remainsdominant as evidenced by the ‘No one else’ in the responses from the survey.Flexible work arrangements enable NUMs to a better work life balance. NUMs who work a nineday fortnight report improvement in their mental well-being, although in compensation otherdays often extend over ten hours. The NIBBIG Work Life Balance report 200712 supports theNUMS need for flexible self managed work hours and the opportunity to job share. Mature agedNUMs expressed a desire to job share and identified it as a way of nurturing and supportingsenior staff with families or back from maternity leave to consider senior nursing roles.(Recommendation 2, 9)The ideal roleThe Consultation groups ended with a discussion centred on what an ideal role could look like.The consensus was to refocus the role on clinical leadership and provide support in the form ofadministration work. The NUMs felt that better preparation and skilled development for the rolewould make the NUM position more attractive. This requires redefining the position and gainingagreement across the nursing profession on the core functions of the NUM role. The other grade7 roles would then line up and provide more effective professional relationships which ultimatelyensure better patient care.(See Appendix 5/6) 12 Queensland Health and Queensland Nurses Union. 2007. Nursing Interest Based Bargaining (NIBB) Project report. Work Life Balance. http://www.health.qld.gov.au/eb/nursing_ibb/work_life_bal.pdf 27 Bondas, T. 2006. Paths to nursing leadership. Journal of Nursing Management, 14: 332-339. 29
  31. 31. ConclusionThe NUM role has expanded in scope to the degree it is now recognised as being difficult torecruit and retain highly skilled nursing staff into this position. The NUM project has identifiedkey issues within the role to address to avert a potentially worsening workforce crisis.There are strong arguments for Queensland Health to implement a framework with coreresponsibilities for the NUM role. This can be used to provide consistency within the role acrossthe state. Other grade 7 roles can then be aligned alongside to ensure a career pathway for futurenurse leaders within the streams of management, clinical, education and research. The frameworkwould also provide consistency within the role for core responsibilities, qualification and skillsdevelopment.Queensland Health is going through rapid change with systems and process being put in placewhich should ultimately enable the NUM to realise more efficient and effective work practices.However, without the right training and mentoring, NUMs will view them with suspicion andsceptic. The Nurse Unit Manager has the ability to provide strong leadership when provided withopportunities to develop the right skill set. Optimising the role ensures effective use of this finiteresource. Providing administrative and reorganising work practices will support the role, improvejob satisfaction and assist with succession planning.Recommendations address the key issues which impact on recruitment and retention, successionplanning and job satisfaction. Outcomes from implementation of the recommendations will resultin the development of highly skilled and knowledgeable NUMs who provide proactive strongleadership and positively affect patient outcomes and service provision.30
  32. 32. Appendix 1: A full description of the perceived current responsibilities of the NUMClinical leadership Clinical governance Education and researchClinical coordinator Change management Transition program governancePatient flow/discharge planning Coordinator of quality activities New graduate interviews and programDriving models of care/ Audits overseerWard rounds with medical staff Risk management Project managerCoordinator of patient information Infection control monitor MentorCase manager Waste management monitor Orientation of staff including juniorSupervision Accreditation coordinator medical staff and studentsCase conferencing Ministerial correspondence Staff aware of unit protocolsManager of waiting lists Policy and procedure coordinator Own professional developmentCrisis management daily Professional practice coordinator needs-attend workshops, conferences,Works clinically to cover sick leave, Incident reporting networks for clinical areaskill mix issues, support heavy workload Complaints managementperiods Work Place Health and safetyDriving evidence based clinical care coordinatorMonitor clinical indicatorsLeading and managing people Business management Materials managementRostering-input, planning, meets award Workforce planning Equipment purchasing – incudesrequirements Service planning and service getting quotesPay enquiries profile report Repairs and maintenanceManagement of leave – annual, sick, Budget build-up contribution Mediation level managementmaternity, study – BPF and Scorecards Meetings with Sales RepsProfessional development allowance Performance indicator reporting IT technician, photocopier/faxand leave. Daily data management – HoursMovement forms and Position per patient day/FTEOccupancy status Business case writingPerformance Appraisals DSS and FAMMIS, Lattice, ESP,Grievance, debriefings, staff support HBSICSRecruitment including writing Job Patient Acuity systemsdescriptions, interviews, panels, Filing/emails/correspondenceSelection reports, referee checks and Meetings/Minute writinginforming employees Capital works and redevelopmentMaintain skill mix levels to ensure safe involvementpatient careSuccession planningCoordinate and chair ward meetings,write up minutesMaintain QLD registration and annualpractising certExtrasPatient and staff counsellorAccommodation and travel organiserCar maintenance/transportDebriefingCoordinating multi disciplinary teamEscorting patientsOn call public holidays 31
  33. 33. Appendix 2: Desirable skills and attributes (formal and informal)Personal characteristics Formal qualifications Orientation Acquired skillsTrustworthy Bachelor of Nursing or RN Supernumery period Business management (BPFHonest, approachable, training (Hospital) Orientation/Resource training)positive Post Graduate management/ Manual Service planningLeader leadership course Mentorship Conflict resolutionVision Political astutenessRole model IT training/data managementGood listener Risk analysis/IncidentTolerance, resilience, managementpatience People managementAdvocate for staff/ Counselling/active listeningpatients NetworkingProblem solver Research trainingMotivated, creativesense of humourFlexibilityEthical32
  34. 34. Appendix 3: Barriers and Enablers to performing roleBarriersNo specific orientation to role, Lack of staff /skill mixComplex information systems – lattice, Transient nature of staff (agency rural and remote)FAMMIS, QHEPS hard to navigate to find things Lack of support from other grade7 roles, Clinical educator,No A/O support Clinical nurseHospital rules, culture, structure ConsultantLack of HR support (inconsistent information) Magnet status is more workOffice space (sharing) Generation x, y needs, less flexible rosteringIT knowledge Equipment shortage/Clinical supply practicesInterruptions (phone calls, people demanding attention) (inappropriate supplies and not timely) Expected to manage projects redevelopment in with every thing elseEnablersGood staff/team work Patient complimentsAutonomy Task transfer of administration to AOPeer supportTime to do projects/redevelopment off lineEducational supportIT support/internet access/mobile technologyHR and Business supportAccess to study leaveDiversity of job/challenges 33
  35. 35. Appendix 4:Nurse Unit Manager Project questionnaire – pre consultation groupsThis questionnaire is designed to form the basis of discussion for the consultation groups discussing therole of the Nurse Unit Manager as part of the recommendations for EB6. This work is the foundation forfuture workforce planning and Industrial Relations negotiations. Please complete the questionnaire prior toattending the group. 1. Why did you become a Nurse Unit Manager? (please ). Professional development Make a difference to patient care There was no one else Other (please state) 2. Are you appointed to the role? (please ) Permanent Acting in the role 3. How long have you been employed as a NUM? (please ) 12 months 1-2 years 3-5 years 6-10 years 10 years 4. Have you undertaken any education to assist in this role? Please state the highest level of education you have attained and the name of the course? (please ) Workshop Short course Hospital certificate Graduate certificate Graduate Diploma Masters Degree PhD Was the course provided through QH or outside the organisation? Was it beneficial? What do you consider the barriers to performing the role to the standard you would like? (please ) Lack of time to complete work Lack of dedicated office/admin time Work force shortage Lack of training Lack of support (please elaborate) Other (please state) 5. Are you seriously thinking about leaving this role? (please ) Yes No If yes indicate why. 6. What changes need to be made to make you stay or enhance your ability to perform the role? (Please key areas for consideration and comment) Clinical Support Human resource responsibilities Information management Quality and safety responsibilities Business responsibilities Other (please state) Contact person: Kaye Hewson, Project officer, Office of the Chief Nursing Officer, QH ext 3234 1035 kaye_hewson@health.qld.gov.au34
  36. 36. Appendix 5: Ideal role – ideas from consultation groups Clinical Succession planning/education Resources • Not included in numbers • Remuneration – shift differentials • CNC support • Model of care driver • Mentorship • Career structure to support Assistant • Not expert but clinically • Work shadowing NUM role competent • Business management/cost centre • Administration support • Clinical leader/credible management • Where Workforce Units exist they pick • Visible • BPF training up more of the paper work associated • Constructive professional • NUM prep course with recruitment relationship with Nursing • Development plan for succession • Peer support network Director planning • Blackberry/Notebook • Structured career pathway • Clinical education support • IT training • People management Other responsibilities Other Work Life Balance • Off line time for specific • Time to look at bigger picture • Flexible work hours – 9 day fortnight/ projects/redevelopment • Hourly on-call rate job share • Meetings scheduled to fit in • IT access/turnaround/service • Remote access with clinical business agreement more efficient • Union support for performance • PAD process streamline • Job description rewrite/ formal role management for management evaluation • Recognition of time spent at work with • On call public holidays shared across managing toil all grade 7 roles • Autonomy 35
  37. 37. Appendix 6: Core purpose of NUM roleCore purpose of NUM role Statement of role purpose Conceptual Framework Clinical leadership Clinical Business governance Leadership Management Professional Human, physical profession of advocacy and financial Operational Nursing resource requirements Midwifery Enabling management facilitating: Quality and Safety - change Continuous Occupational - development performance Health and safety 0f others improvementIndividual position Position Description reflect core functions of descriptions role Note: acknowledgement given to ‘Take the Lead’ Project NSW, NSW Health36
  38. 38. References1. IBB: nursing. Nursing Interest Based Bargaining Implementation Group. http://qheps.health.qld.gov.au/ebb/ibb/Nursing/nibbig.htm2. Queensland Health Queensland Nurses Union. 2007. Nursing Interest Based Bargaining (NIBB) Project Report. Workforce Recruitment and Retention. http://qheps.health.qld.gov.au/eb6/ibb/Nursing/Recruitment%20and%20Retention%20Final%20 Report%2004.07.07.pdf3. ACCIRRT. 2003. Simply the Best Workplaces in Australia, Working Paper 88, University of Sydney.4. Queensland Health. 2008. Nursing and Midwifery Classification Structure HR Policy B7. http://www.health.qld.gov.au/hrpolicies/resourcing/b_7.pdf5. Mercer Human Resource Group. 2000. Nurse Unit Manager Classification Review.6. University of Southern Queensland. 2007. Report of ‘better workplaces’ Queensland Health Staff Opinion Survey http://qheps.health.qld.gov.au/central/workforce/casu_final_wct.pdf7. Queensland Health. 2007. Nursing Labour Workforce Survey. http://qheps.health.qld.gov.au/waru/docs/nurses_lfs_2007.pdf8. Hawes, S. 2008. ‘Take the Lead’. Strengthening the role of the Nursing and Midwifery Unit Managers across NSW. New South Wales, Nursing and Midwifery Office, NSW Health. http://www.health.nsw.gov.au/nursing/pdf/nmforum_take_lead_pres_apr08.pdf9. Duffield, C., Kearin, M., Johnston, J., and Leonard. 2007. The impact of hospital structure and restructuring on the nursing workforce. Australian Journal of Advanced Nursing, 24(3): 42-4610. Stanley, D. 2006. Role conflict: leaders and managers. Nursing Management, 13(5): 31-37.11. Paliadelis, P. 2005. Rural nursing unit managers: education and support for the role. Rural and Remote Health 5: 325. (on line)12. Queensland Health and Queensland Nurses Union. 2007. Nursing Interest Based Bargaining (NIBB) Project report. Work Life Balance http://www.health.qld.gov.au/eb/nursing_ibb/work_life_bal.pdf13. Paliadelis, P., Cruickshrank, M. Sheridan, A. 2007. Caring for each other: how do nurse managers ‘manage’ their role? Journal of Nursing Management, 15: 830- 837.14. Chiarella, M. 2007. Redesigning models of patient care delivery and organisation: building collegial generosity in response to workplace challenges. Australian Health Review, 31(S1): S109-s115.15. NHS Modernisation Agency. 2004. 10 High Impact Changes for service Improvement and Delivery. A guide for NHS leaders.16. Newman, S. 2005. The impact of health reform on nurse managers and their management of nursing services: a study of the Australian Context. Paper presented at 6th Annual Interdisciplinary Research Conference, Trinity College, Dublin. 37
  39. 39. 17. Kramer, M. Maguire, P., Brewer, B. et al. 2007. Nurse Manager Support. What is it? Structures and Practices That Promote it. Nursing Administration Quarterly 31, (4), 325-340.18. Jones, J., Lowe, M., Burns, C. Donaldson, P., Abbey, J. Abbey, B. 2008. Practice Partnership Model: An innovative approach for nursing at The Prince Charles Hospital (TPCH). Final Report of the Skillmix Research Project. QH and QUT.19. Day, G.E., Minichiello, V. and Madison, J. 2006. Nursing Morale: what does the literature reveal? Australian Health Review, 30 (4), 516-524.20. Walker, K. 2007. Fast-track for fast times: Catching and keeping Generation Y in the nursing workforce. Contemporary Nurse, 24(2): 147-158.21. Jarman, H. 2007. Consultant nurses as clinical leaders. Nursing Management, 14(3): 22-2622. Gallo, K. 2007. The New Nurse Manager: A Leadership Development Program Paves the Road to Success. Nurse Leader, 5(5): 28-32.23. Redman, R.W. 2006. Leadership Succession Planning. The Journal of Nursing Administration, 36(6): 292-297.24. Wolf, G.A., Bradle, J. Greenhouse, P. 2006. Investment in the Future. A 3-Level Approach for developing the Health care Leaders of Tomorrow. The Journal of Nursing Administration, 36(6): 331-336.25. Kleinams, C.S. 2003. Leadership Roles, Competencies, and Education. How Prepared Are Our Nurse Managers? Journal of Nurse Administration, 33(9): 451-455.26. Laschinger, H. Wong, C. 2007. A profile of the Structure and Impact of Nursing Management in Canadian Hospitals. Final Report for CHSRF Open Grants Competition project # RC1-0964-06.27. Bondas, T. 2006. Paths to nursing leadership. Journal of Nursing Management, 14: 332-339.38
  40. 40. Bibliography• Qld Health Business planning framework: a tool for nursing workload management (4th edition) Resource manual.• ACT Health Nursing Midwifery Work Level Standards, June 2007 JUMCC.• MED-E-SERV 2008, Health Services Workforce Development Programs, Clinicians Development Education Service.• Nurses (Victorian Public Health Sector) 2007 Multiple Business Agreement, 2007-2011. 39

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