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Managerial roles are valuable for any enterprise. The possibility to exercise the regulatory functions and the ability to see the environment where employees work from the external perspective helps the organization implement various changes and understand its stronger and weaker sides. Choosing the leader for a conflicting group of people is a challenging task for every manager. The necessity to boost productivity, decrease conflicts, and unite various personalities for the common goal needs a quick solution as the staff might work less efficiently, which can result in the loss of patients and bad reputation. That is why selecting a leader needs profound learning of leadership skills and their detection within the right personality who agrees to occupy such a position. The implementation of changes anticipates understanding of the managerial situation within an establishment. For this reason, numerous change theories can be applicable for the nursing practice. Lippitt, Watson, and Westley (1958) provide a detailed explanation of change theory, peculiar for the nursing management. A topic of interest is Colorado Pain Center where nurses have no team lead, the charge nurse, to control their productivity and boost the team spirit.

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Often, conflicts between nurses decrease productivity and demonstrate the organization to patients from the negative side. That is why a profound understanding of change and the environment within the team is what an efficient change needs, which is the key reason to selecting Lippitt’s change theory (Lippitt et al., 1958). Creating the image of the charge nurse’s personality, regardless of their qualification, is vital for the selection of the appropriate candidate, capable to work in conflicting conditions and eradicate violence in the team. Choosing Lippitt’s change theory and hiring the charge nurse with a democratic leadership style who will exercise stronger control is a short-term goal. At the same time, anticipating the increase of work efficiency is the long-term goal for Colorado Pain because the charge nurse’s responsibility is to arrange the equal workload for all nurses, schedule the shifts, eradicate conflicts and laziness, create fair working conditions. Achieving such goals will mean greater patient satisfaction and the confirmed reputation of the establishment with skilled and supportive personnel.

The Reasons for Introducing the Charge Nurse Position at Colorado Pain Hospital

Hospitals belong to a special organization type as the proper distribution of working obligations, schedule, and assessment of the qualification of workers can impact the degree of medical assistance. The aid provided to the patient determines their further health condition and life. That is why the managerial mission at hospitals can influence the life of other people. The introduction of the role of the Charge Nurse (CN) for the Surgery Department is the result of two primary reasons – the absence of conflict management and the shift schedule. Frequent conflict situations between the regular nurses (RN) reduce productivity at Colorado Pain, which results in lower work quality. Therefore, establishing an effective work of the personnel anticipates the availability of a team lead role for the position.

Conflicts, as the first reason, require the acquisition of team communication with the help of team lead. Such a role enables the positioning of the department on top management level and allows communicating the internal, external, and organizational level issues. For example, Bender, Connelly, and Brown (2013) based their study on the results of RN and Head Physician’s survey and the claim that the primary obligations of the lead to evaluate were “utilizing effective communication for conflict resolution” (p. 167). In this case, CN is the personality whose obligation is to discuss difficulties and think over the motivation and rational solutions for the problem. The communicative side of the CN’s role motivates entering this job position.

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The second reason lies in the absence of a regular schedule of work shifts and bonus system for regular nurses. These factors demotivate the personnel and lead to the tension of the environment for doctors as well. Colorado Pain’s service is narrow as compared to usual hospitals, and pain origination is more difficult to detect (Colorado Pain, n.d.). According to the information on its website, the facility offers an invasive or surgical therapy methods to eradicate pain symptoms with the use of implants, Botox, and so on (“Pain treatments,” n.d.). Due to the absence of schedule, the nurses select going to the night shift at informal group discussions, which results in unequal working hours. The proving fact is 14 online reviews taken from yelp.com (“Recommended reviews,” n.d.), where 6 negative feedbacks from patients are about the delay in the provision of aid services, the absence of medical personnel at scheduled and paid appointments, and wrong prescriptions. Such conditions have necessitated creating a survey for the patients to outline the relevant leadership skills for a clinical nurse.

Therefore, the absence of the regular workload distribution for RNs and frequent conflicts at work among them constitute two reasons of introducing the CN role for Colorado Pain. Negative feedbacks at popular online resources result in a negative customer experience and the establishment risks losing its patients. As Colorado Pain is a small-size company employing less than 200 people, proper nursing is vital for the competitive advantage over large-scale health service establishments. A wide array of procedures needs a well-managed nursing department, delivering a timely and professional assistance. This aspiration could become the common idea of improving the nursing aid and make RNs understand the necessity of the shift work arrangement.

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Change Theory for Management Proposal

The selection of the theoretical basis for change management is important for the scientific grounding of nursing management. As changes vary depending on each particular case, defining the framework for the change can offer clear objectives. The nursing management sphere differs in theoretical approaches in management, thus necessitating the analysis of change theory. Finding the relevant framework will allow an efficient change implementation with a proper function distribution for every participant of the change. The more stages the change implementation has, the easier it is to understand the importance of each participant of the change and make them motivated, thus efficient.

When considering the nursing practice in the light of change theories, one can find numerous approaches. The most detailed framework for the change implementation is Lippitt’s theory of change.

The relevance of change theory and creating the change implementation framework require a certain type of change. For example, Yoder-Wise (2014) distinguishes planned and unplanned changes and shows that each change theory is efficient for a certain change category. The necessity of implementing Lippitt’s approach is the relevant framework for a planned change type. As Colorado Pain management has not created the job position of CN, this change is predicted as the need of managing RNs’ work belongs to the primary managerial functions. As doctors have their management team as the Board of Directors, HR manager, and Head Physician regulating their working obligations, the nursing personnel does not have a definite manager to arrange their work. That is why this type of change is vital and planned.

The initial stage of the elements of the nursing process is outlining the problem, which is identifying the general impression of nursing aid at Colorado Pain. Finding negative feedbacks and investigating their origination have led to detecting lack of proper management to arrange appointments and schedule a timely medical assistance for the patients with the help of nurses (Appendix 1). The capacity and motivation for change lie in creating the budget costs for hiring the necessary person and defining job responsibilities of the future CN (Appendix 3). In this case, the nursing staff is a change agent as they are to be the principal implementers of the change process. Their scope of work will determine the degree of support and professional assistance to patients.

The progressive change objective is establishing mutual cooperation among the nurses, which will result in better provision of nursing aid to the patients and the improved quality of the nursing assistance. A definite role for the change implementation is a CN as they will be in charge of five principal managerial functions: planning, staffing, controlling, organizing, and directing (Yoder-Wise, 2014). Maintaining the mentioned functions is the fifth component of the change implementation for Colorado Pain. Sherwood and Barnsteiner (2017) suggest a simple visual system of interaction, due to which the nursing management systems promote the improvement of the nursing aid provision.

The given Figure shows that all personnel contribute to developing the high level of healthcare service, thus involving the nursing department in the common aim of acquiring more patients regarded as clients, which makes the nurses assume responsibility. Such an understanding assigns a common motivation of the establishment, including doctors, managers, and Head Physician to their own intentions. When the common goal becomes understandable and attainable due to the qualification maintenance and evaluation, conflicts decrease, which updates the CN as the specialist who will not need further assistance of the supporting managers or mentors. Defining the framework for the change proposal for Colorado Pain as a seven-stage model is extensive and efficient for the healthcare establishment. Even though the change is a planned action, it needs a proper understanding of stages and their implementation in order to ensure its efficiency. Finding the change objectives and Quality and Safety Education for Nurses (QSEN) competencies will help understand better which particular area of knowledge the nurse should possess in terms of nursing leadership and nursing management.

Change Objectives and QSEN Competencies in the Light of Nursing Leadership and Management

Establishing a qualitative nursing aid in Colorado Pain needs two goals following each other. They help the organization succeed in delivering a professional, timely assistance and ensure a quick recovery as well as high degree of service satisfaction. The differences in nursing leadership and nursing management will help understand better the essence of change objectives as well as select the vital QSEN competence. The overall change of introduction of the Charge Nurse’s role covers two objectives. identifying the goals to achieve. Defining change objectives as specific, measurable, achievable, relevant. and time-based (S.M.A.R.T) allows dividing them into short-term and long-term ones (Yoder-Wise, 2014). Such a distinction enables building exact timeframes and considering all actions to take for making a successful change.

Short-term goal oversees selecting a medical worker for the Charge Nurse position, relying on the job description to post on various web resources (Appendix 3). The time base frame to achieve this goal is November 2017 (Appendix 2). The necessary yearly budget for this purpose, including salary, purchasing the office furniture, and necessary stationery, is $81,487.54 (Appendix 1) with the gross salary to offer $80,250 (“Charge Nurse salaries,” 2017) and net income of $57,194.05 as the tax rate is 28.73 %, with the taxable income $69,850 (“Colorado State tax calculator,” n.d.). The mentioned budget is within the Center’s financial possibilities and affordable in terms of financial operations.

The achievement of the long-term goal encompasses several change stages and identifies the improvements in nursing aid for the patients by means of raising the work efficiency of regular nurses. The goal anticipates creating the shift work schedule by the CN, familiarizing with the internal and external team environment with the assistance of top managers (Appendix 1). After arranging the schedule, the CN establishes the work regime with daily meetings and discussing the accomplishments or difficulties the nurses might have. Creating round tables and openness during meetings eradicates the conflicts as nurses realize responsibility for the improvement of the health center’s reputation. Boosting team spirit in promoting a supportive and respectful relationship between the regular nurses will help eradicate the conflicts and envy because of unequal workload.

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When analyzing QSEN competencies essential for the assisting personnel, medical qualification does not limit the skills vital for an efficient nursing. Particularly, the academic achievements of nurses identify six quality and safety competences such as patient care, teamwork and collaboration, evidence-based practice, quality improvement, safety and informatics (Lyle-Edrosolo & Waxman, 2016). The current situation at Colorado Pain Center needs teamwork and collaboration competence among the six because conflicts and misunderstandings between the regular nurses comprise the primary reason of patients’ dissatisfaction. The ability to level the conflicting interests by arranging a favorable inner environment is the basis of a successful realization of the long-term objective of improving the nursing aid quality. Improving the team spirit among the nursing staff needs the nursing leader who is capable of developing this competence.

The nursing leadership implies finding the relevant style of behavior and creating psychological conditions that can integrate the team and promote productivity at work. This leadership can be formally delegated or informal. In the current situation leadership is both formal and informal as CN motivates the personnel through the working communication at daily meetings. The nursing management anticipates planning, controlling, coordinating, staffing, organizing (Yoder-Wise, 2014). The initial implementation of change starts with planning, which presupposes establishing the goals as well as detecting the reasons of change and necessity of its implementation.

Organizing change deals with the analysis of the internal and external environment and creating the framework for taking the exact steps. After this, the staffing process takes place, thus implementing the short-term objective of hiring a CN. During the trial period, the top managers instruct the CN on the work to be done (Appendix 1; Bender et al., 2013). Afterwards, the CN coordinates and controls nursing aid maintenance and keeps motivating and respectful relations in the nursing department to boost productivity, instant assistance, and qualified medical aid provision to the patients. Training programs and coaching are possible if the CN manifests lack of qualification in any of QSEN competences, among which teamwork and collaboration will be of primary value. The successful result will mean a sufficient improvement of the quality of nursing care based on the patients’ positive feedback. Managing and leading change in the health center encompasses theoretical frameworks, academic achievements, and personal traits from the CN. The efficiency and completeness of this change needs finding the ways of resistance as well as regulatory guidelines, equalizing the macro level of healthcare sector. Learning the political environment and regulatory guidelines will help understand the legal and managerial bases, peculiar for all hospitals.

Political Environment and Regulatory Guidelines Impact

Creating a documental regulation for any company is the basis of its controlled and efficient activity. Medical establishments have their own guidelines related to the regulation of their work. The regulatory guidelines integrate a set of obligations and recommendations for establishing the framework for preventing the violations of corporate etiquette, maintaining the workable atmosphere, increasing work efficiency, and improving quality of the nursing aid to the patients. When analyzing the case of Colorado Pain, one can see that some regulatory guidelines are missing, which has resulted in the failure to provide timely medical assistance. Moreover, some doctors were absent at the appointments (Recommended reviews,” n.d.). In defining policy and politics, Yoder-Wise (2014) differentiates the terms though both mean interaction of an individual and organization. Policy denotes a definite plan implementation, for example, in the Colorado Pain case, a change implementation. Politics permeates all organizations, workplaces, and families. The overall character of the political environment lacks the attention to the nursing department, referring to the RNs as junior assisting personnel. Yet, knowing the patients’ feedbacks promotes the penetration of the change implication within Colorado Pain Center. The top managers determine the scope of work for doctors and nurses and evaluate their skills (Colorado Pain, n.d.). After the introduction of the CN position, the CN as the team lead of the nursing department becomes accountable to the Head Physician.

At the same time, introducing the CN position will need the changes in management. Previously, the Board of Directors approved the working instructions for the staff at Colorado Pain, and the HR distributed them according to their roles and oversaw their maintenance. At present, the function of distribution will belong to the CN. Therefore, the nursing department staff will be accountable to the CN who will determine and evaluate the work of RNs. At the same time, the evaluation process for RNs and the CN will enroll the Head Physician and the HR manager. The controlling function of the company’s politics and following the job instructions by the CN will promote a proper change implementation and increase its positive effects. Introducing the job position of the CN will cover policy and political changes as the current management has failed to provide a proper medical aid. Enrolling the personnel for the qualification evaluation of the nurses will help understand the missing measurements and learn from the previous mistakes. Two-sided politics allowing suggestions or sharing ideas will be possible due to bringing the CN’s role to the department since they will be able to communicate with top managers and the workers they will be responsible for.

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Psychological and Structural Sources of Resistance

Occupying the job position of the CN in the conditions of a conflicting inner environment meets a certain type of resistance. The study of resistance resources can help predict the realistic results of change implementation into the nursing practice if its degree of effectiveness is not sufficient. Thus, Sherwood and Barnsteiner (2017) differentiate structural and psychological sources of resistance. The former ones include disbeliefs, mistrust, insecurity, and other unsetting feelings that impact the general environment within the organization (Lyle-Edrosolo & Waxman, 2016). The latter ones denote financial difficulties, equipment supply, or facilities. Considering the case of Colorado Pain Center each type of resistance is present.

The psychological resistance is expressed as mistrust and disregard within the nursing department as well as possible prejudice from the top management. This type of resistance might hinder the process of selecting the CN among the available regular nurses. Choosing one nurse from the currently working employees could cause envy and increase the conflicts among the nursing staff. Moreover, none of them had enough experience or performed managerial obligations before (Colorado Pain, n.d.). This type of resistance is prevalent as nurses also have difficulties in adapting to a new lead and accepting their leading style. The structural resistance identifies salary negotiations and the impossibility to provide higher salary or more facilities for arranging the workplace of the CN. Salary negotiation after ending the selection process was the financial resistance of the Head Physician to raising the salary (Bender et al., 2013). Nevertheless, the pay rise is motivated decision as the establishment needs the CN to regulate the conflicts within department.

Any change implementation is characterized by the resistance to change. Each of the department workers needs to adapt to the lead and realize the value of his/her role and their functions within the establishment. The top management should also realize that quality aid is vital for their facility so they need to ensure qualitative service. Boosting trust, aiming at preserving patients can help overcome the obstacles to change. Resistance is a normal and customary sign that a change applies into the work of the medical center. The eradication of resistance is better for promoting the efficiency of the change agent even though the change needs more investments.

Conclusions

Introducing the position of CN at Colorado Pain is a planned and expected change as the Health Center does not hold such a position. The absence of the CN role conditions the difficulties between the colleagues within the nursing department, which reflects on the deterioration of the quality of nursing service delivery to the patients. Applying the 7-stage change management theory is relevant for the planned change type and it helps all participants understand their contribution and ensure certain function to boost the effectiveness of the change to implement. Furthermore, outlining a timeline and budget for the change implementation as well as creating the job description is vital for the search for the suitable person with all necessary skills and qualification. Dividing the change proposal into the hiring of the nurse and the implementation of leadership and management strategies presuppose the implementation of short-term and long-term goals, the achievement of which deals with finance from the side of the establishment and conflicts between the nursing team as the sources of resistance. A detailed salary discussion promotes the motivation of the CN and helps the candidate make the choices in favor of Colorado Pain. A motivated lead can boost motivation within the team as well.

The combination of a friendly environment and a strict regulatory policy eradicates the conflicts between the nurses. Daily meetings and trainings ensure the high level of QSEN competences, create bonds within the team, and make it the environment of skilled people by rejecting gossip and envy as the result of the improper working schedule and the total absence of control. That is why teamwork and collaboration are the preferable QSEN competences, relevant for Colorado Pain’s inner environment as they prove to be the primary factor of showing personal care to the patients as well as demonstrating a high qualification and quick reaction to their requests.

Appendices

Appendix 1.

Proposal Implementation Timeline

Managerial Action Personnel Engaged Deadline
1. Selection process for a Charge Nurse job

· Creating the job description

· Selecting the candidates

· Interviewing process

· Approval process

· Salary negotiation

· Contract signing

HR Manager

Head Physician or Attorney

 

Nov. 2017

-Oct. 5

-Oct., 15-28

-Oct 15-28

-Oct 29-31

-Oct 27-29

-Oct 29-31

2. Workspace creation and redesign

-Purchasing the repair materials

-Repair works

Office Manager

Repair workers

Sept.27-Oct. 15
3. Trial period for the Charge Nurse

-Instructing the charge nurse regarding their job

– Adaptation

-Discussion of the issues related to nurse shifts and nurse management situation

-Charge Nurse’s evaluation process

Charge Nurse and Head Physician

 

Nov. 2017-Jan. 2018
4. Creating the nursing department under the supervision of the Charge Nurse

-Distributing workload for regular night shift and dayshift nurses

-Daily meetings to discuss the current difficulties if there are any and workload summary from the nurses

-Managing the nursing care for the current patients

-Task distribution

– Creating and spreading the feedback form for the patients

Charge Nurse and Registered Nurses Dec.2017-Jan.2018

Daily

Daily

Dec. 2017-Mar.2018

5. Nurse evaluation process

· Creating an evaluation checklist and filling in by the Charge Nurse

· Receiving patients’ feedback regarding the work of nurses based on the feedback results

Charge Nurse HR manager, Head Physician April, 2018. Then quarterly
6. Evaluating the nursing aids

· Analyzing the changes in patient care

· Considering patients’ feedback before and after the changes

· Evaluating the psychological and working environment in the nursing department

HR Manager, Head Physician April, 2018. Then quarterly
7. Delegating managerial obligations to CN Head Physician, HR May, 2018

Appendix 2.

Budget Expenses for the Charge Nurse Position Implementation, USD (Charge Nurse Salaries in Denver, Colorado, 2017; “Colorado State tax calculator,” n.d.).

Annual Gross Charge Nurse Salary $80,250
Taxable income $69,850
After Tax $57,194.05
Tax Rate (Relevant for Denver, CO), % 28.73 %
Stationery and Office Equipment Costs, USD
Office equipment, US $

-PC

-printer

-desk

-chair

350

249,99

172,55

380,92

Stationery, $:

-pen (5)

-pencils (2)

-notebook (2)

4

6

5

Workplace redesign, USD$ 695,63*
Total $81,487.54

Appendix 3.

Charge Nurse Job Description

Job Requirements

  • Manage the nursing care for all patients in the surgery unit during the shift
  • Schedule the shifts and assign the shift schedule to the personnel engaged
  • Distribute the shift’s tasks among all nurses in the unit and coordinate with the surgeons needing assistance
  • Recognize changes in patients’ condition and respond appropriately
  • Supervise Nursing Aides as they complete their assigned tasks and point to any changes or improvements that need to be made
  • Define any issues that can cause any damage or injuries to the patients or staff
  • Inform physicians of the changes in patients’ condition or whether they need any additional care
  • Skills Needed
  • Regular Nurse License Required
  • BSc in Nursing Required (MSc in Nursing Preferred)
  • 5+years of experience nursing in the hospital environment
  • 2+ years in supervisory nursing
  • Proficiency in hospital safety procedures and practices
  • High level of detail orientation
  • Excellent leadership skills
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