Organizational Review 1
Running Head: ORGANIZATIONAL REVIEW
Organizational Review of a Nursing Unit and its Manager
Justin Lieberman
Montclair State University
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Description and Purpose of Organization
The organization studied here is in the category of public
health, a major hospital. This hospital services a wide area
that encompasses both urban and suburban populations, which the
hospital states are between 300-350,000 people. These areas
range from very low socio-economic status to the wealthiest
families in America. It provides the area with inpatient and
outpatient services, medical, surgical, and psychological. The
main building provides the non-psychological support, while a
separate building a mile away houses the psychiatric departments
(Princeton, 2004, Annual report section, para. 5).
There are many departments in the hospital, including
business, nutrition, environmental services, maintenance,
marketing, human resources, social services, and nursing.
Within the nursing department, the hospital’s largest; there are
medical, surgical, critical care, labor and delivery, recovery,
oncology, pediatrics, and emergency services. The hierarchy of
the hospital has the president at the top, with a board created
to vote on the most major issues. Beneath them are heads of
many of the departments who act as liaisons between the
administrators and the regular staff. In addition, there are
sub-managers for each nursing unit who are in charge of their
own units. This paper will focus on just one of these units,
one of the medical-surgical floors (hereafter described as A1),
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specializing in post-operative treatment of general, orthopedic,
gynecological, and urological surgeries.
Description of major problem
The major problem the unit faces is the tradeoff between
patient care values and the hospital’s ability to make money.
Currently, the hospital is one of the most profitable hospitals
in its area, at the same time however, the patient satisfaction
scores and overall appearance to the public are both very low.
Administration and staff each have different reasons for the
problems. Administration cites the shortage of available
nursing staff in the area as the main reason their patient
satisfaction remains low. The staff understands this; however
they blame the administration for not offering more to
prospective employees. This is where the unit’s major
organizational problem comes in. There is a lot of pressure on
the NCC (nursing care coordinator, or unit manager) to make sure
the patient satisfaction scores stay high, while at the same
time keeping our beds full while emptying out critical care
floors. The NCC seems very unable to handle this pressure.
While her outside life brings her many problems, on the unit she
berates staff members, refuses to grant days off, is unwilling
to listen to her employees, and often focuses on issues that are
not as important as other ones. This has caused her staff to
increase their absenteeism, work poorly, and even leave the job.
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Organizational Chart
History of problem and any solutions tried
This problem is a new one on A1. In November of 2003, the
current NCC took over the position, which had been vacated about
a year earlier (we will call her JD). While the staff remained
in high spirits, new staff was not being hired in a timely
fashion, and certain administrative tasks were not getting done.
The hospital interviewed a few candidates for the job, however
the staff of A1 turned each one down, citing reasons such as a
lack of experience and unfriendliness. Finally, the hospital
was left with no choice as state inspection time was nearing, so
they hired somebody who had experience in a similar position in
another hospital. This was the only true solution tried.
People involved
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There are three types of non-managerial staff members on A1
that are affected by JD’s management, spread across three
shifts. The day shift, 7am to 330pm, has three types of staff
members, plus an assistant manager. The most important are the
RNs, who are the primary patient caregivers, charged with the
most responsibility for each patient. Included in this
responsibility is the fact that they are licensed by the state,
and are legally responsible to care for their own patients in a
manner which is responsible, timely, and to the patient’s
benefit. Second are the nursing assistants (NAs). They act as
helpers to the RNs by doing small tasks and assisting in nursing
duties. There is also one unit clerk, who is given the duty of
organizing many of day to day operations of the floor as well as
directing all calls from the inside or outside. One of the RNs
is also an ANCC, or assistant nursing care coordinator. She is
in charge of the floor and will take care of non-administrative
tasks that need to be accomplished. During a normal day shift,
there are 5-7 RNs, 3-5 NAs, and one unit clerk. The evening
shift, from 3pm to 1130pm has the same setup, only with one less
RN and one less NA on average. The night shift runs a bit
differently, from 11pm to 7am, there are usually 3-4 RNs, 2-3
NAs, and no unit clerk. For the sake of this research, the
position on A1 does not matter, as the whole staff is affected
by JD in mostly the same manner.
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Leadership Theory
One of the approaches Industrial / Organizational
Psychologists take towards leadership is the transformational
leadership theory. There are a few dimensions to this theory,
but it can be summarized by two main factors. First, a
transformational leader motivates his or her followers to
perform in an enhanced manner by nurturing and transforming
followers’ beliefs. In stark contrast, a transactional leader
rules on an exchange relationship where followers receive
compensation by complying with the leader (2 330).
Why theory applies
JD’s leadership style is clearly that of a transactional
leader. Reinhardt (2004) points out that a transactional leader
“clarifies what performance is required and how to meet
expectations.” One of her biggest issues is always with her
evaluations. She points out organization mandated job
requirements to each employee, and explains to them that they
must meet these requirements or else they will not get their
raise. The transformational leader would not be defined in this
way.
More importantly, JD lacks many of the qualities that a
transformational leader embodies. For example, one of the keys
to a transformational leadership style is communication
(Reinhardt, 2004). Instead of trying to speak to people on an
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equal level, JD speaks down to people and is very rude as well.
Another example is that a transformational leader is an
intelligent and rational problem solver (Reinhardt, 2004).
However, when a problem occurs, JD does not demonstrate the
ability to understand what the problem is or how to solve it,
and instead yells and screams at anybody who is in earshot.
Possible Solutions
It can be very difficult to change somebody’s communication
style; however JD needs to work hard on doing this. One of her
biggest problems is that she separates herself from other
employees by always pulling her rank. Instead of answering the
phone or calling people as “I am the NCC of the floor,” she
could define herself like the rest of the employees, with her
first name. In addition, being rude really makes for an
ineffectual management style. When JD answers her employees
with “WHAT?” instead of “how can I help you,” she loses their
attention quickly. She needs to go out of her way to be polite
to staff members, enhancing their lines of communication, and
moving herself towards the transformational leadership method.
The second part of JD’s problem would be even harder to
rectify. As NCC of the floor, JD must be able to solve problems
in a way that shows she has the skills and rationality a
managing nurse should have. In order to do this, JD must show
the rest of the staff her expertise by going in and doing things
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hands on, not giving tasks to others. In the same manner, if
something small goes wrong, she cannot explode. When something
on the scale of running out of index cards happens, JD needs to
calmly ask the person in charge of ordering to make sure we get
more. She should not scream about how we need them NOW, and how
she doesn’t understand how the floor operates in such an
“unprofessional manner.”
Fit of solutions and theory
The solutions presented here would bring JD in line with
what the quintessential transformational manager would be. A
positive way of communicating by JD, and thus a more
transformational style, would encourage a more open workplace.
This would in turn encourage group-generated resolutions and
create a more team-based environment (Reinhardt, 2004). Theory
also suggests that some irrationality may be good; if change is
needed sometimes an “out of the box” approach is best. But the
problem is that during hectic times, a transformational leader
will bring stability and rationality to the table, to bring
things back in order (Reinhardt, 2004). JD does not do this.
Benefits of solution implementation
There would be multiple benefits to the implementations of
the solution. Changing communication style to that of a
transformational leader is a very obvious difference. Employees
in outside departments would think differently of the situation
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on A1. As it stands, they know when they speak to JD, she is a
nasty woman. Because of this, people are less likely to help A1
if they need things. Word would not get around that there is a
“mean manager” on the floor, which makes it difficult to get new
employees. People tell their friends, who then avoid coming to
work on A1. On a similar note, current employees are often
insulted by the manner in which they are spoken to by JD. This
causes them to either lose motivation or leave the job.
Showing JD’s skills to everybody would be beneficial in a
very important way. Veteran nurses would gain a lot of faith in
her abilities, and she would earn their respect. At the same
time, newer nurses could look up to JD as a mentor or role model
by watching her complete tasks in a skilled manner. Performing
these tasks in a cool, calm manner would have much of the same
effect, plus it would keep everybody else on A1 calm during
situations of crisis. Of course, when people are calm and able
to collect their thoughts, they perform better.
Costs of solution implementation
As far as negatives go, there are only a few items that
could be considered a negative. Sometimes, A1 needs something
done that regular employees are not able to get done. It helps
that JD is able to pick up the phone, explain to the other side
what her position is, and demand something immediately. When
the situation is emergent, as can happen in the health care
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field, this can be used to A1’s advantage. A transformational
leader here may not be able to demand things and explain their
rank. And as part of transformational leadership theory has to
explain, despite the call for rationality, change in an
organization can be good. A1 had the same leadership in place
for many years prior to JD’s arrival, and while a lot of it was
positive, some things needed changing, and JD was able to
influence these things. One could envision a situation where a
transformational leader would not be task oriented enough to
force a change where others may not see that it is necessary.
Motivation Theory
Herzberg’s two-factor theory of motivation describes two
sets of factors; one of which causes job satisfaction, the other
causing job dissatisfaction in its absence. The first of these
is motivational factors, including recognition, responsibility,
and achievement. Herzberg stated that if these factors were
present, motivation on the job would be very high. The second
of these factors include pay, working conditions, and
relationships. He called this “hygiene” (Donkin, 2004).
Why theory applies
JD’s leadership style forces both motivational and hygiene
factors onto the wrong side of the scale. One of her main
problems is that she never recognizes the employees who do a
fine job. When somebody does something out of the ordinary,
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fellow employees congratulate them, but often JD will just have
a snide remark like “I used to always do that when I was a
nurse.” Another issue that A1 has is that JD takes away
responsibilities from various staff members. Whenever a new
nurse has a patient that tends to complain, JD takes that
patient away and gives it to a veteran nurse, saying that the
new nurse “isn’t ready yet.” These types of actions cause the
staff of A1 to lose a lot of motivation.
JD is also infamous for not giving people timely raises or
offering overtime due to budget concerns. This causes people to
feel underpaid and makes them think they do not have the
opportunity to make any more. JD also goes out of her way to
force people to keep on working through lunch breaks, especially
when A1 is very busy. She also expects people to leave their
responsibilities to go to hospital functions so that the floor
“looks good.” In addition, due to reasons previously cited in
this paper, JD is not well liked on a personal level by the
staff. Herzberg’s theory suggests all these factors, when
absent, will cause motivation to decrease.
Possible solutions
A solution to problems that Herzberg cites as motivational
factors increasing job satisfaction can be found and implemented
quite easily. When an employee does something well, JD needs to
let them know that they have succeeded, as well as the other
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staff members. She could submit it to the hospital bulletin or
even post it on a board for everybody to see. She also needs to
give responsibility to everybody, not just the oldest veteran
nurses. A new nurse needs to sometimes get that “important”
patient. If one of the board members is having surgery, let the
new nurse take the patient. This kind of action will foster a
sense of responsibility. Changes like this can be made quite
easily by JD and will help A1’s staff become more motivated to
do a good job.
In other units, staff members not only are given the
opportunity to get regular raises above the minimum amount,
their supervisors offer a lot of overtime when staff is needed.
In contrast, JD is so concerned with A1’s budget that she would
rather have her unit be understaffed then to pay a few people
overtime. In addition, JD never gives above average scores on
bi-yearly evaluations, meaning that staff members only get the
minimum salary increase. Many others in the hospital get
positive evaluations, giving them bonuses to their salary. JD
needs to realize that people are happy and stay because of
money. If she were to stop worrying so much about her budget,
which has never gone over, she could give out a little bit of
overtime where it is needed, and people would be much happier.
Along with the lack of monetary compensation, JD is forcing
employees to go above and beyond while they shirk their own
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responsibilities. JD needs to make sure that everybody has
things finished before she asks them to go and attend a hospital
wide meeting. This would allow employees to complete their work
in a timely fashion and not have to stay past their shift to do
it (S. Anderson, personal communication, November 22nd, 2004).
Fit of solutions and theory
The solutions presented would fit with Herzberg’s theory.
First, helping the hygienic factors would reduce any job
dissatisfaction that is presented on A1. This means that if the
employees get fair pay and are treated well, chances are they
won’t become dissatisfied with their jobs. In turn, this will
allow the motivators to take effect. Recognition and giving
people responsibilities will help employees go beyond
satisfaction to a state of motivation. This will make A1 run in
a much more efficient manner, as happy, motivated employees do a
better job.
Benefits of solution implementation
In implementing the solutions described for motivation, A1
and JD would get a boost in production and satisfaction, leading
to motivation. Recognition’s positives are very clear; people
like being recognized for good deeds, and will strive harder in
other situations to do well again. This means that if a nurse
goes out of her way to help another nurse who is having problems
with a patient, and she is recognized for this, the motivation
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will be there the next time the situation comes up. This
fosters a working environment that is not only friendlier with
the staff overall, but also a better situation for the patients
involved. Giving new nurses the responsibility to care for
difficult or special needs patients also would be a great boost
to the staff. Often, new staff members are pushed to the back
and not allowed to make a big splash like this. Giving them
duty of caring for one of these “important” patients will make
them feel more wanted, and in turn, will be more likely to stay
on A1 for a longer time.
Positive results would be accomplished for the solutions
encouraged to fix hygienic factors as well. Higher pay and a
better working environment come with multiple benefits. First,
employees outside A1 and outside the hospital would hear about
these opportunities, and would certainly be more likely to apply
to work on the floor. This would happen because A1’s current
employees would be happier at a job where they were compensated
well. Second, since staff would be happier at the job, they
would be less likely to call out sick or quit. This in turn
would keep the rest of the staff in high spirits because they
would not be perennially understaffed and under a lot of
pressure.
Costs of solution implementation
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There are some negatives to the solutions given by
Herzberg’s theory. By recognizing certain employees, you always
run the risk of not getting everybody who has done something
good, and thus alienating them. The same idea goes for pay
increases. If you give certain people higher scores on
evaluations, giving them bigger raises, what about the people
who don’t get it? JD would have to explain herself to people
who were not benefiting from these changes in both situations,
and that is a difficult thing to deal with.
What I learned from this project
As an employee on this unit for more than four years, the
changes that have taken place on the unit had become apparent to
me almost immediately after JD’s arrival. This project allowed
me to really concentrate on a few of JD’s traits and examine
them from a social scientific point of view. One thing that I
come away with the strongest is a new feel for the true lack of
communication that goes on, along with the task-orientation that
has taken over. For a long time, the staff of A1 was able to
really speak their minds in group meetings and on a one to one
basis and let the administration know how they felt about
situations. Also, responsibilities were completed in a timely
manner, without constant reminders of what they needed to do. A
whole new sense of what is the right thing to do on the unit now
is in command. I felt some of these things before, but after
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looking at leadership and motivational theories, and applying it
to JD, everything makes more sense.
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References
Reinhardt, A. C. (2004). Discourse on the transformational
leader metanarrative or finding the right person for the
job. Advances in Nursing Science, 27, 21-31.
Rafferty, A.E., & Griffin, M. A. (2004). Dimensions of
transformational leadership: conceptual and empirical
extensions. The Leadership Quarterly, 15, 329-354.
Donkin, R. (2004). Motivation? Retrieved November 20th, 2004,
from http://richarddonkin.com/motivation.htm.
Princeton Healthcare System. (n.d.). Retrieved November 6th,
2004, from http://www.mcp.org.
