The nurse-patient relationship is at the heart of health care. Nurses have to be managed with the same suave, assurance and grace that they have to apply to patients, writes behavior based health and safety consultant Mabila Mathebula in a paper on ‘New roles and competencies for South African nursing managers’ presented to the 2011 SA Nurses’ Conference in Sandton, Johannesburg.
Nursing challenges in South Africa include migration, absenteeism, health services transformation, ethical dilemmas, poverty, crime and HIV /Aids (Jooste, 2004).
These challenges are a smoke signal, a warning of a growing fire in the nursing profession that could prove impossible to extinguish.
Nurses and their status are of overpowering importance to society. Ralph Linton in 1936 wrote that workers occupy a status, but play a role. Our society is full of status occupants, but few role players.
We have a ‘script’ of nursing roles. There are numerous management aspects to this profession. This paper examines managerial roles in the nursing profession.
Research has shown that management is a skill to master. Managers need certain competencies. If a hospital is mismanaged, patients bear the brunt of incompetence.
Medical science paradigms
Three eras in medical science determined development of the nursing profession;
Era 1860 to 1950, of materialistic or physicalistic medicine, was characterised by the discovery of therapies like drugs, surgery, radiation. The era was influenced by Sir Isaac Newton’s physics theories.
According to this thinking, the universe and the body is a clockwork functioning according to deterministic, causal principles. Effects of mind and unconsciousness were relegated to the background.
Martin Luther and John Calvin lived in an era without ether and penicillin, when the life expectancy was recorded as thirty years (Yancey, 1998).
Nursing suffered from Newtonian physics. The world is not mechanistic. Astronomer James Jeans wrote; “The universe begins to look more like a giant though, not like a great machine.” (Sheehy et al, 1996).
Era 1950 to 1990s, of mind-body medicine, recognises perceptions, emotions, attitudes, thoughts, and perceived meanings to affect the body. Dossey (1993) argues that thoughts deserve to be called ‘therapeutic’.
Era 2000s, of non local health and wellness, recognise that mind is not confined in space or time. Physicist Erwin Schrodinger wrote; “Mind by its very nature is a singular tantum… the overall number of minds is just one”.
We are at the cusp of a new medical era. We need a change in health care paradigm. Managers must realise that the health care management ‘emperor’ has no ‘clothes’. Many leaders ignore the fact that the organisational system they represent is no longer functional.
Holistic health care
The nursing profession is in a challenging phase. The torch of new ideas is still dim.
According to former SA prime minister gen Jan Smuts (1927), “Holism underlies the synthetic tendency in the universe, and is the principle which makes for the origin and progress of wholeness in the universe”.
Once a nurse embraces gen JC Smuts’ definition of holism, it would be simple to recognise that surgery, neuro cytology, and even psychiatry, are a single discipline, and ought not to be separated.
Carson (1999) warned about narrow-minded practice of physical medicine. He argued that health care is not just a provider and protector, but should be involved in issues that affect quality of life; mental, spiritual, physical, and society.
If medical practitioners alienate themselves from society, they are as cancer to a healthy body. According to Korten (1999) cancer occurs when a genetic damage causes a cell to forget that its part in a larger body.
Cancer cells pursue their own independent growth, without regard to consequences for the whole, and destroy the body it should feed. The same applies to medical practitioners; if they fail to be holistic, society would perish.
New health care competencies
Deming threw down the gauntlet to management: “Management must feel pain and dissatisfaction with past performance and have the courage to change. They must break out of line, even to the point of exile among their peers. There must be a burning desire to transform their style of management.” (Dennis, 1997).
Management is in a crisis. Why do some organisations choose to perish rather than change? Some organisations can not learn. Some professions suffer from paradigm paralysis, their central nervous system has been damaged (Sheehy et al, 1996).
Rules of management are constantly changing, and managers are ill prepared and increasingly frustrated in dealing with change. Change is complex and difficult to comprehend and operationalise.
Leaders v managers
Warren Bennis wrote that leaders are made, or trained, not born. Organisations are usually over-managed and under-led (Broadbent, 2007).
Leaders work on a system, not within a system. Leaders create opportunities, not react to opportunities. Leaders seek opportunities, instead of controlling risks of opportunities. Leaders adapt rules instead of enforcing rules. Leaders offer vision instead of following direction. Leaders motivate instead of control. Leaders inspire instead of co-ordinate. Leaders coach instead of instruct. (Broadbent, 2007)
Psychologists have shown that “under circumstances of uncertainty or unusual challenge and difficulty, people look for help in understanding about what matters, what to do, what direction to take, and what they should not do. Providing people with these answers is the essence of leadership” (Taffinder, 2000)
Types of intelligence
New competencies, knowledge and concepts are essential to delivering holistic health care. Health care management should apply IQ, EQ and SQ, in synergy, in the 21st century.
The advent of emotional intelligence (EQ) has sparked interest among psychologists, academics and business leaders. IQ (Intelligence Quotient) was historically considered key to identifying potential and capability of individual employees. We need to add spiritual intelligence (SQ) to the intelligence equation.
IQ is fixed and EQ is variable. The Japanese has a word for EQ; Kaizen, continuous improvement. The assumption behind Kaizen is that there is no perfect answer in a changing world.
Managers in the nursing profession are faced with a plethora of issues that warrant IQ: strategic planning, career development, migration, shoestring budgeting, transformation of health services, employment equity, and staff retention.
Manage by Emotional Intelligence (EQ)
According to Fourie (2004) empathy is one of the difficult parts of being manager. It comes from practice. He summed up empathy:
• Sincerity, speak true feelings. Face issues head on.
• Show genuine concern for people, not mere formality.
• Invite discussions about work and personal issues.
• Create a supportive climate.
• Offer help and assistance.
EQ enables managers to manage issues such as anger, racism, HIV ostracism, team management, diversity management. Managers have to be multi skilled and holistic in their thinking. In the 50s managers were engrossed in activities and not in processes or strategies. Troubleshooting was a norm, but today’s managers are faced with new challenges and new competencies are needed to deal with these challenges.
Manage by Spiritual Intelligence (SQ)
Kathleen Raine wrote; “Our society has lost the dimension of meaning and values, one could say the sacred, in arts and in life itself.”
Maladies of the soul are multifaceted: anxiety, addictions, depression, emptiness, loneliness, relationship breakdown, violence, war, spiritual hunger (Zukav, 1990). People realize that titles and material do not give happiness, they crave to connect with the Absolute.
The search for meaning in life is demonstrated by Rudyard Kiplin in ‘The Miracle of Purun Bhagat’. A Prime Minister of a state in India, Sir Purun Dass, resigns to become a Sunnyasi, a holy man. He settles on a hilltop overlooking a village, and finds true meaning or self realization in poor people, animals and nature. He dies trying to save the village. Villagers never knew that he was Sir Purun Dass, KCIE, DCL, PhD.
How many patients die while nurses demonstrate industrial action? Spiritually intelligence means reluctance to cause harm. In the Vedic literature, Ahimsa Paramo Dharmah, Non-injury, is the highest virtue. in thought, word and deed.
SA Rabbi Warren Goldstein (2010) reinforces Sivananda’s point of view; “In Jewish tradition, when a baby is born we pray that the child grows up committed to good religious values, family, and good deeds. We do not ask for fame, fortune, success, degrees or status”.
Indications of highly developed SQ include:
• Capacity to be flexible, actively and spontaneously adaptive.
• High degree of self-awareness.
• Capacity to face and use suffering.
• Capacity to face and transcend pain.
• Inspired by vision and values.
• Reluctance to cause unnecessary harm.
• Tendency to see connections between diverse things, holisim.
• Tendency to ask Why or What if, and seek fundamental answers.
• Being ‘field independent’, working against convention (Zohar and Marshall, 2000).
In our spiritually stunted world, managers need to develop SQ to deal with a myriad of challenges like idiopathic disorders, diseases whose causes are unknown.
James Kouzes and Barry Poster (1995) researched characteristics that employees most admire in leaders. Since the early 1980 the top four characteristics have not changed; honesty, forward looking, inspiring, competent. They refer to these four qualities as credibility.
Smith and Kelly (1997) argue that leadership is based on six dimensions: conviction, character, care, courage, composure, and competence. Leaders are expected to add value to their position.
Nursing managers’ roles
Sociologists say that he who occupies a status must also play the role. Managers plan, organise, coordinate, control, but it is difficult to put these four functions into practice. These four words introduced by Henri Fayol tell us little about the role of a manager.
Management goes beyond these four roles. They have to communicate, energise, care, council, coach, discipline, direct, monitor, innovate, facilitate. [These roles are discussed in the full and referenced paper by Mabila Mathebula, presented to the SA Nurses’ Conference 2011, in Sandton, Johannesburg. This report is an abstract]
Managerial roles and competencies
Managerial roles should be matched with a number of competencies, as listed below;
• Collaboration: Ability to help others find consensus on issues or disagreements.
• Diagnosis: Ability to research, to reveal, and to understand the root causes of organization, process, or team problems.
• Feedback: Communicating and insuring authentic two-way communication.
• Self Awareness: knowing one’s internal states, preferences, resources, and intuitions.
• Self-Regulation: Managing one’s internal states, impulses, and resources.
• Motivation: Emotional tendencies that guide or facilitate reaching goals.
• Empathy: Awareness of others’ feelings, needs, and concerns.
• Social Skills: Adeptness at inducing desirable responses in others.
• Questioning or cross examination skills: Objectively gathering information by various questioning methods to stimulate creativity and learning.
• Relationship Skills: Successful application of verbal and nonverbal communication skills.
• Intervention: Ability to objectively diagnose a situation and know what action is appropriate to take.
• Group process: Understanding of group development processes.
Health care culture change
We need thinkers of great thoughts and doers of great deeds in nursing management. It is not enough to enact a role without mastering competencies associated with that role. The major challenge of this century is to move from a blame culture to energizing employees.
Employees must be recognised emotionally and intellectually by their managers and given timeous positive feedback. The second best option is negative feedback with guidance, and third best option is negative feedback, but the worst management is no feedback.
Managers should acknowledge that employees are appreciating assets to be developed, as well as depreciating cost to be managed.
Health care policy making has a long way to go. The noble nursing profession is called to rise to proper management and a radical paradigm shift.
• This report is an extract from a full and referenced paper by health and safety management consultant Mabila Mathebula, presented to the SA Nurses’ Conference 2011, in Sandton, Johannesburg.
PHOTO; Mabia Mathebula is MD of MM Consulting.