Somebody once told me that I was a good nurse director, my response was to laugh as I thought that they were joking. This is probably another blog post about why as nurses we are not good at accepting compliments! The statement was actually meant as a compliment and when I asked why they said this the answer was because you say “no”.
Saying no was not something that came easily to me, rewind to my younger self working as a staff nurse, the thought of saying no would have horrified me. In the senior positions that I have held over the last decade, I have learnt that as a leader there are times when you have to say no.
Why is saying no so difficult?
Why do we find it so hard to say no and why does it cause so much anxiety when we do? The patients in our care rely on us to say no to keep them safe, let’s just think about this scenario for a moment.
Just imagine for a moment that you are one of the few wards in the hospital with an empty bed. Your permanent staffing profile is built to an occupancy of 85% which means when your ward is fully occupied you have to make up the difference with an agency or casual staff. At peak holiday times it is likely that the additional staff can’t be found. You are left with the prospect of offering overtime and those awful double shifts to your permanent staff. You are asked to take a patient with high care needs, who is obese and requires four nurses at least to assist with all activities of daily living, into your last remaining bed. Your staff are exhausted as the ward has been full for weeks, the acuity of patients are highly dependent and you have run out of favours for overtime and double shifts. So what do you do, take the patient and suffer the consequences? You know that your sickness rates are going to go through the roof which only increases your agency use and blows a hole in the ward budget. You also know that there is a direct correlation between increased agency use and an increase in medication errors, falls and pressure injuries. The dilemma of being a leader faced with mounting pressure to be seen to be helping the wider hospital or looking after the patients that you have and the health and well being of your staff? Your staff avoid eye contact because they fear that you are going to tell them that their workload is going to get even more difficult for the foreseeable future.
When a hospital is under pressure that pressure gets passed down the line. Directives are given and expected to be acted on placing an already stretched ward under even more pressure. As a nurse manager, the accountability for the patients in your care and your staff sits with you. It is no defence to say in a court of law that someone told you to do something, even if that someone is more senior than you. What is expected of you is that you use your professional judgment and make decisions based on that professional judgement to keep your patients and staff safe. To be able to confidently say no you need to articulate the potential risks that will arise from a potentially unsafe situation. You need to be able to remove the emotions from the situation and practically list the risks and how those risks can be mitigated or not. Then consider who else do you need to involve to help you identify and manage the risks. For moving and handling the OSH team is a really useful resource who can look at the practicalities of is it possible to safely care for this patient on your ward. The OSH team can also source equipment that can make caring for a patient who has bariatric care needs easier. Saying no to someone is always easier if you can offer a solution rather than saying no outright and lends itself to wider teamwork.
For example, think creatively, can you offer to take a patient who is not as highly dependant from another area that creates movement within the hospital? Reviewing the patients that you currently have on the ward with the team leaders and understanding which of those patients are ready to go home and understanding the hold-ups. Reviewing these patients with members of the nursing and Allied Health team can often create movement or at the very least gives you an indication of the barriers to discharge and points of escalation to senior hospital managers. Escalation can often make things happen and it is important to be clear about what the issue is, what needs to happen and who needs to take action. This needs to be done verbally at the bed meetings and followed up in writing with an email so that you have a record of the conversation.
Regular reviews of long-stay patients with the multi-disciplinary team is a good planning measure that as a nurse manager you can put into place. This help to ensure that you are being proactive in managing the patients and creating movement within your ward and the hospital that prevents the knee jerk responses that often happen in a pressured hospital environment where beds are in short supply.
Early morning management huddle
Another effective management technique is to have a daily early morning meeting with the senior clinical nurses to understand the patient admissions and discharges for the day along with any sickness or staffing issues. This allows for early identification of any potential problems that may arise and provides an opportunity for solutions to be considered before the day begins.
Managing under pressure is never easy and as a nurse manager, everyone looks to you for guidance and direction. One of the things I am often asked is how do you use mindfulness in situations of high pressure. There are many different ways to practice mindfulness. The simplest and most effective technique that I use is to stop, press the pause button and count to 10 slowly in my head and breath in and out as I am counting. This slows down your breathing and your instinct to respond immediately and buys you a little time to breathe and think before responding. It is never good to fire off emails or have a phone conversation when you are under pressure and annoyed. Write the email as a draft but don’t send straight away. Reviewing later when calmer will always ensure that you respond in a way that is not coming from a place of frustration and feeling pressured. I always end up amending emails after waiting and re-reading and reflecting on the content by asking myself how will the person who reads this email feel? We have to remember that we are part of a larger team and you will need the help of the person that you are emailing at some point.
Interacting cooperatively, living authentically through knowing and holding onto your personal values, deploying your strengths, and having a good level of emotional awareness and regulation are two of the components of the resilience at work tool that I use when working with individual nurses.
This series of leadership blogs are examples of everyday nursing issues that I coach with nurses and midwives with.
Do you find it difficult to say no? I can help you contact me for a free 30-minute discovery call