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.