Introduction
Leadership and management tend to be regarded as distinct but related phenomena. The latter is typically concerned with the organization of the workflow (its planning, implementation, and control) while the former is usually related to the development and change, which is fuelled by enabling, motivating, and inspiring people (Algahtani, 2014). These definitions suit the nursing perspective of leadership and management (Wong, Cummings, & Ducharme, 2013). Apart from that, nursing leadership is closely connected to advocacy, in which case nurse leaders work to improve the healthcare and wellbeing of their community by developing, advocating for, and implementing health-related policies (Haycock-Stuart & Kean, 2013; Vaismoradi, Bondas, Salsali, Jasper, & Turunen, 2012). One of the nursing roles that are closely related to leadership and management is that of the head nurse of an Emergency Department (ED), and the present paper is devoted to its investigation.
In Australia, as well as other countries (Crossan & Shacklock, 2013), nurses are a major part of the healthcare workforce that is crucial for the community health (Duffield, Roche, Twigg, Williams, & Clarke, 2016, p. 2219). Apart from that, EDs are a significant element of modern healthcare that provides care for the injured and promotes the health of the community (Shoqirat, 2013). However, HNEDs are not just highly competent ED nurses; they also carry out managerial duties and take the role of the leader of their department. The combination of their detailed knowledge of the work of an ED nurse and the position of a manager and leader results in the ability of HNEDs to successfully manage the department and improve the performance of its nurses (Bamford, Wong, & Laschinger, 2013). In general, the role of an HNED is extremely extensive, which can result in noticeable occupational stress, but the education, training, and experience of the nurses help them to correspond to their numerous role requirements and provides HNED with the opportunity to contribute to the quality of ED care.
Role Scope
The scope of practice for a particular profession is “the full spectrum of roles, functions, responsibilities, activities and decision-making capacity that individuals within that profession are educated, competent and authorized to perform” (Nursing and Midwifery Board of Australia [NMBA], 2007, p. 1). The role of HNEDs is complex, but as healthcare managers, they have the primary purpose of ensuring the quality of care and patient safety in their department (Pegram, Grainger, Jones, & While, 2015). From the point of view of the enactment of the role of a manager, HNEDs are expected to organize and coordinate the work of their staff and perform planning and decision-making activities (Wang, Anthony, & Kuo, 2016). HNEDs also play a crucial role in enabling communication between their subordinates and superior managers; effective communication and cooperation, in turn, are very important for nursing settings (Walsh et al., 2015), including ED (Gilardi, Guglielmetti, & Pravettoni, 2013). Moreover, HNEDs are often involved in the organization of training for their unit to ensure that the knowledge of ED nurses is continually upgraded (Atakro, Ninnoni, Adatara, Gross, & Agbavor, 2016, p. 4). In certain cases, HNEDs can also be required to evaluate the performance of their staff and define the learning and organizational needs of their department (Wang et al., 2016, p. 43). As leaders, HNEDs enact their role when they work to motivate, inspire, and enable ED nurses to act and foster improvements in their department. Also, the role that nurses play from the point of view of advocacy, especially in the field of healthcare policy development and implementation, is applicable to HNEDs as nursing leaders (Haycock-Stuart & Kean, 2013).
Given the large scope of practice, the examples of HNED activities can be numerous. For instance, Zohar, Werber, Marom, Curlau, and Blondheim (2017) discuss in detail the messages that HNED can communicate to their nurses and also demonstrate that these messages can significantly affect the nurses’ behaviors. Similarly, Shirazi et al. (2015) consider nurse empowerment activities as a significant part of the HNED role. Also, workplace governance is directly connected to HNEDs since they are involved in multiple managerial and leadership-related activities as the key figures in the management of ED nurses (Wang et al., 2016).
With respect to leadership, it is noteworthy that a variety of styles and characteristics, which tend to have an influence on the effectiveness of leadership, can be adopted by HNEDs (Bamford et al., 2013; Shirazi et al., 2015; Vaismoradi et al., 2012). Also, the outcomes for the nurses can be affected by the leadership style; for instance, Laschinger, Wong, and Grau (2012) show that authentic empowering leadership helps to reduce emotional exhaustion in nurses. Finally, patient outcomes can also be affected by the leadership style; for example, Wong et al. (2013) show that transformational leadership tends to have this effect. Thus, HNEDs need to have some knowledge of the leadership and managerial tools that they can use.
The Regulation of Practice
The scope of HNEDs’ practice is rather extensive, which proves the significance of their roles while also calling for an equally extensive regulation. High-quality education, especially specialized education that specifically targets emergency nursing, is crucial for HNEDs (Atakro et al., 2016; Damkliang, Considine, Kent, & Street, 2015). Apparently, the experience is also very helpful, including professional and managerial or leadership experience; it can be regarded as an enabler that improves the quality of work of HNEDs as well as their confidence (Pegram et al., 2015, p. 325). Apart from that, there are formal requirements that HNEDs must take into account.
From the point of view of legal regulation, the practice of Australian HNED is guided by healthcare-related acts. A major act that is of significance for HNED is the Health Practitioner Regulation National Law Act (2009), which defines the general legislation for all health practitioners and includes important information on accreditation, registration, conduct, and other aspects of HNED work. Apart from that, the Act establishes the National Boards, which regulate specific health professions, and the Australian Health Practitioner Regulation Agency, which is a body that is supposed to support the Boards in a variety of ways (Health Practitioner Regulation National Law Act, 2009, pp. 83-84, 88-90). Of the Boards, the Nursing and Midwifery Board of Australia is responsible for determining standards for HNED education and practice. Also, the Health Workforce Australia can be mentioned as an organization that is busy with determining the needs and difficulties in healthcare workforce management in Australia and searching for policy-related means that can improve the situation (Buchan, Twigg, Dussault, Duffield, & Stone, 2015, pp. 164-165). Thus, the practice of HNEDs is predominantly regulated by general rather than role-specific legislation and organizations.
An Australian HNED is supposed to take into account the regulations, standards, and guidelines of the Nursing and Midwifery Board of Australia. In particular, the codes of ethics and professional conduct for the nurses of Australia that are provided by the Nursing and Midwifery Board of Australia [NMBA] (2008a; 2008b) are of importance for HNED. Apart from that, the organization establishes the standards of practice for nurses that are applicable to any area of practice, including ED (Nursing and Midwifery Board of Australia [NMBA], 2016b). These standards are continually updated to ensure the relevance of the requirements included in them (Nursing and Midwifery Board of Australia, 2016a). Finally, NMBA (2007) offers help for nurses in the form of tools that can improve practice. For example, NMBA (2007) has developed a national decision-making framework.
NMBA’s (2008b) Code of Professional Conduct contains ten principles that require safe, competent, respectful, standardized, legal, and ethical conduct. The Code of Ethics of NMBA (2008a) includes eight requirements that also promote ethical, impartial, culturally sensitive, and responsible care. The seven standards of NMBA (2016b) demand that registered nurses make their practice legally immaculate, evidence-based, planned, safe, high-quality, and culturally sensitive; nurses are also supposed to ensure their own safety and ability to provide care. Apart from that, Australian nurses are required to develop meaningful relationships with their patients and peers. Finally, the standards demand comprehensive assessments and the evaluation of outcomes, which should be used to improve practice. All these requirements are applicable to HNEDs.
To sum up, NMBA (2008b; 2016b) offers comprehensive but generalized requirements, which can indeed regulate the practice of HNEDs. From the two codes and the standards, it can be concluded that the Board demands evidence-based and patient-centered care. As a result, the values of safety, competency, respect, and ethical practice appear to be central to the role of HNED.
Role Benefits and Outcomes
HNEDs are very important for the improvement of the outcomes of care (Wang et al., 2016). A systematic review by Jennings, Clifford, Fox, O’Connell, and Gardner (2015) demonstrates that while the relationship between the performance of ED nurses and the cost efficiency of care cannot be detected, their work improves the quality of healthcare as well as the time of waiting, and, ultimately, the satisfaction of the clients. Apart from that, HNEDs have great clinical leadership potential, which helps them to improve the experiences of their subordinates and organize their units, improving their efficiency (Bamford et al., 2013).
As nurse leaders, HNEDs can facilitate and improve care through their capacity to develop the environment and atmosphere of safe care and the ability to integrate the activities of various healthcare providers (Vaismoradi et al., 2012). Zohar et al. (2017) show that the modification of head nurse messages can significantly improve the safety culture of their departments, leading to statistically relevant positive changes in safety and time climate as well as patient care. Naturally, these changes result in positive outcomes for patients and nurses.
Advocacy-related outcomes also seem to be of importance for patients, communities, and HNEDs themselves (Haycock-Stuart & Kean, 2013). However, Shoqirat (2013) points out that while ED nurses are being encouraged to contribute to community health promotion, the majority of them do not actually report being involved in the process or seeking to do so. In other words, while the role of HNEDs seems to require advocacy-related activities, it is not typically regarded as a primary or even significant aim.
In general, the outcomes of the role and related benefits are predominantly of use for patients as well as HNEDs’ subordinates. It is noteworthy that the stress of ED work can be significantly modified by successful managerial interventions (Adriaenssens, De Gucht, & Maes, 2013). Given the fact that HNEDs tend to be well-acquainted with the needs of ED nurses, they seem to be particularly capable of improving their experiences (Bamford et al., 2013). All these factors prove the significance of the role of HNEDs once again.
Role Experiences and Development Needs
The experiences of HNEDs are likely to vary across countries, but certain aspects of the role seem to be reported by nurses from various settings (Buchan et al., 2015; Crossan & Shacklock, 2013). For example, Atakro et al. (2016) report that in Ghana, ED nurses tend to experience understaffing, insufficient or ineffective training in certain areas of knowledge that they need to fulfill their role, and the lack of necessary resources (pp. 1, 4). The authors explain the issues by the lack of institutions that can offer quality emergency training to professionals in Africa. However, Pegram et al. (2015) survey nurses of the UK and discover that they also report training issues (their own and those of other staff members), resources shortage, and understaffing (pp. 318-319). The latter is classified as a particularly significant contributor to occupational stress by the respondents of the study by Pegram et al. (2015).
Understaffing is also characteristic of Australia, and it has been shown to decrease nurses’ ability to provide quality care (Duffield et al., 2016). Oostveen, Mathijssen, and Vermeulen (2015) point out that understaffing is an issue for the Netherlands as well, and they suggest that the key reason for the issue in developed countries is the rising demand for healthcare, which can be connected, among other things, to the aging population. It also apparently results in nurses being overworked (Kaddourah, Khalidi, Abu-Shaheen, & Al-Tannir, 2013). Oostveen et al. (2015) also point out that understaffing can be related to the lack of proper communication between managers and nurses where nurses’ opinions are overlooked. In this respect, the role HNEDs appears to become crucial as well since it is theoretically capable of improving communication between ED nurses and senior managers (Wang et al., 2016).
As a result, it appears that the mentioned issues are universal, even though the reasons for their existence may differ for countries with different levels of development, and they tend to result in a decreased quality of care. It is noteworthy that at least two of the mentioned issues seem to be acknowledged by the Australian government, including the Department of Health (2015). This fact can be supported by the governmental initiative “More doctors and nurses for Emergency Departments,” which was developed to improve the education of ED specialists in Australia to boost their numbers and quality of training (Department of Health, 2015, p. 51).
Concerning other experiences, ED nurses report the emotional strain and stress, which result from the specifics of the patients’ injuries, and the communication with the families of patients, which can lead to negative or positive situations (Atakro et al., 2016). There is also the possibility of the lack of support from subordinates, peers, or senior managers as well as the excessive pressure that results from the expectations of the surrounding people (Ericsson & Augustinsson, 2015; Pegram et al., 2015; Wang et al., 2016). Similarly, unsupportive environments can be an issue (Bamford et al., 2013). Moreover, nursing experiences are not isolated from global events; for example, the recent economic recession has resulted in difficulties with payments and employment (Buchan et al., 2015). Given the fact that HNEDs are often involved in staffing, scheduling, and training, these events are likely to result in multiple negative experiences for them, including personal and department-related ones.
The study by Pegram et al. (2015) also reports the possibility of positive experiences of manager nurses, which includes the feeling of being valued and accepted by coworkers (p. 325). It is apparent, however, that the investigation of negative experiences seems to prevail among the works that have been included in the current literature review. Still, the review cannot be regarded as perfectly representative, and the observation can be explained by the fact that the negative experiences of nurses are typically related to issues that require solutions. The cited works either attempt to point out the issues or search for their solutions, which are vitally important activities.
Educational and Job Satisfaction Needs
With respect to the needs of HNEDs, education and job satisfaction can be mentioned. Atakro et al. (2016) regard training at work as the most appropriate solution for the issue of insufficient training. Similarly, Damkliang et al. (2015) discuss educational interventions that can be applied to working ED nurses. Morphet, Kent, Plummer, and Considine (2016) also demonstrate that ED nurses can and should continue their education after graduation, and show that Australian nurses have multiple educational opportunities, many of which are provided by healthcare organizations. However, the availability of educational resources may vary for territories. Since communication skills are crucial for HNED (Gilardi et al., 2013; Wang et al., 2016), relevant training can also be regarded as a need. Also, Paganini et al. (2016) point out the significance of disaster preparedness for ED, including its nurses.
Job satisfaction is another important need for HNEDs as well as other nurses. This aspect of nurses’ work depends on multiple factors, including payment and other forms of recognition, schedule and other conditions of the work, relationships in the department and with other managers, and the availability of career and professional growth options (Crossan & Shacklock, 2013; Pegram et al., 2015). Apart from that, job satisfaction is affected by the negative experiences discussed above and the occupational stress considered below. Thus, the mechanisms of improving job satisfaction for HNEDs seem to be apparent.
Role Strengths and Weaknesses
When compared to other nurses, HNEDs have more autonomy and a greater opportunity to make a difference, which is rarely a possibility for regular nurses (Kaddourah et al., 2013; Oostveen et al., 2015). This feature of the role can be regarded as a significant strength, which can be used to achieve the desired outcomes at the level of ED or the community. However, the present analysis seems to indicate that current researchers are predominantly interested in the topic of issues that are related to the role. This observation can be explained by the fact that the studies are apparently aimed at resolving these issues, but the resulting report may seem to be rather one-sided as a result. Still, the present study allows to state that occupational stress is a complex and significant weakness of the role of HNEDs.
Occupational Stress
The role of an HNED is naturally correlated with specific occupational stress (Atakro et al., 2016; Pegram et al., 2015). Yuwanich, Sandmark, and Akhavan (2016) state that the problem mostly originates from the unpredictability of ED events as well as their stressfulness, which is also pointed out by Atakro et al. (2016). Yuwanich et al. (2016) suggest that ED can be a more stressful environment than some of the other nursing settings. The complexity of the work, which increases with new developments in the field of healthcare, is also a significant stressor (Ericsson & Augustinsson, 2015). The increasing workload (which is correlated with understaffing) can lead to job dissatisfaction and stress as well (Bamford et al., 2013).
Stress is a definite weakness in the role that is correlated with health issues (Yuwanich et al., 2016). While the specific outcomes of stress vary depending on personal and organizational characteristics, stress tends to reduce job satisfaction while contributing to emotional burnout (Admi & Eilon-Moshe, 2016; Adriaenssens et al., 2013). It follows from this fact that the issue is capable of undermining HNEDs’ health, thus making it difficult for them to carry out their practice: the quality of care tends to depend on nurses’ well-being (Admi & Eilon-Moshe, 2016). Yuwanich et al. (2016) show that nurses tend to search for ways to manage their stress with relative success; Adriaenssens et al. (2013) also point out that managerial interventions can be of use if they are aimed at improving the organizational predictors of stress. Here, it is noteworthy that HNEDs can be regarded as nurse managers, which implies that they may be required to introduce such interventions or advocate for them on their own. As a result, while the issue of occupational stress is acute, the solutions to it are available to HNEDs.
The Challenge of Development, Implementation, and Evaluation
According to Bryant-Lukosius et al. (2016), there exists a significant knowledge gap in the topic of the development and assessment of nursing roles. The authors view the determination of the methods of development and assessment as a significant step towards the improvement of the management of the roles (which is not limited to standards but also includes various educational and organizational initiative and related funding and so on) (Bryant-Lukosius et al., 2016, p. 205). The authors demonstrate that multiple frameworks for the development and evaluation of the nurse role’s goals and objectives exist, including the Participatory Evidence-Informed Patient-Centred Process, which the authors promote for its qualities, including its evidence-based nature and the focus on the patient. The present study also demonstrates that NMBA (2016b) has developed a framework of standards, even though it can be regarded as very general. In fact, the suggestion of Bryant-Lukosius et al. (2016) about the lack of relevant research seems to coincide with the finding of the current literature review, which indicates that the topic of the role of HNEDs may be rather underrepresented in modern studies. As a result, it can be suggested that the development, implementation, and evaluation of the role is not only challenging; it also requires additional investigation. The present paper can be regarded as an attempt to summarise relevant knowledge, but additional research is clearly required for a deeper understanding of the role of HNEDs.
Conclusion
The present analysis suggests that the topic of the role of HNED is relatively underrepresented in recent literature. However, it is possible to supplement the few articles on this role with those of the roles of ED nurses and head nurses to achieve the following conclusions. First of all, the significance of the role of HNED is difficult to overestimate, and the scope of practice of HNED is most impressive. Basically, HNED is responsible for management and leadership in an ED, which can be exemplified by a vast number of activities that include but are not limited to planning, decision-making, coordinating, motivating, and advocating. The role of HNED can result in positive outcomes for patients and HNEDs’ co-workers; apart from that, the role presupposes active involvement in policy-making, which can be beneficial for HNEDs themselves.
Given the significance of the role, the regulations that are related to it and the educational and training needs of HNEDs are particularly important; also, their job satisfaction is known to affect their productivity in a positive way. The strengths of the role include its increased autonomy, which is rather rare for a nursing role; however, the issues and challenges seem to receive more attention from researchers. Possibly, the focus on issues can be explained by the fact that their elimination is crucial for the success of HNED role enactment. The key weakness of the role is the immense occupational stress which is caused by multiple contributing issues; the stress can be reduced by HNED or specific managerial interventions. The definition, evaluation, and development of the role also seem to be challenging, in particular, because of the relative lack of research on the topic. To sum up, the role of HNED is an extensive subject that requires further investigation with the aim of informing the actions of HNEDs and improving their performance.
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