Introduction
The present paper considers the role of an Emergency Room Head Nurse (ERHN), which combines leadership and managerial responsibilities, specifically within the settings of the Kingdom of Saudi Arabia. Emergency Room (ER) or Department constitutes a type of care settings where “emergency patients are accepted, and critically ill patients are rescued” (Zhu & Wang, 2015, p. 19). The specifics of these settings have an impact on the activities that ERHNs are supposed to perform; in particular, ER work is associated with increased stress and risk of violence (Atakro, Ninnoni, Adatara, Gross, & Agbavor, 2016). Furthermore, because of the combination of clinical, leadership, and managerial responsibilities, ERHNs is a very extensive role with high expectations (Jonson, Pettersson, Rybing, Nilsson, & Prytz, 2017). It is also associated with notable educational needs (Morphet, Kent, Plummer, & Considine, 2016). However, the acquisition of the necessary skills and competencies equips ERHNs to perform their duties in a way that results in positive outcomes for their clients and the profession.
Role Scope and Performance
The research on Saudi Arabian nurses, especially those operating within a specific environment and performing particular roles, is not very extensive, but it is still present. Saudi Arabia has less than 100 years of history, and nursing in it is younger (Al-Hazmi & Windsor, 2013), which might explain the shortage of literature. Furthermore, there is some research on the role of ERHN in other countries, as well as head nurses in different settings. Also, some policy papers are available. Consequently, the scope of the role of ERHN can be explored in the present essay.
Purpose
The general purpose of ERHN consists of ensuring the high quality of nursing care in their ER by enabling its processes and empowering its nurses. This purpose is achieved through the managerial and leadership activities that include, but are not limited to, the establishment and maintenance of policies, coordination of nurses’ actions, management of healthcare resources, development of healthy work environment, problem-solving, decision-making, nurse empowerment, and so on (Bai et al., 2017; Dahshan, Youssef, Aljouaid, Babkeir, & Hassan, 2017; Firouzkouhi, Babaeipour-Divshali, Amrollahimishavan, Vanaki, & Abdollahimohammad, 2016; Jonson et al., 2017). Thus, despite the short and direct purpose statement, the activities that are related to it for ERHN are rather numerous and varied, which indicates that the role is complex.
Common Features of the Scope of the Role
The role scope of ERHN can be characterised by three key features: manager, leader, and clinical nurse. Indeed, while mostly concerned with management and leadership, ERHNs are also involved in clinical duties, especially in case of major emergencies (Jonson et al., 2017). However, as a head nurse, ERHN is also expected to manage and lead ER nurses. The two roles differ; while a manager is concerned with aspects like scheduling, coordination, and organisation, a leader would motivate, engage, and empower (Kantanen, Kaunonen, Helminen, & Suominen, 2017). However, leadership and manager roles are generally interconnected (Kantanen et al., 2017), which is why they are not expected to conflict. Still, it is apparent that ERHN’s role includes three aspects which incorporate multiple functions and responsibilities and require a variety of competencies. The complexity of the role can be highlighted again.
Role Governance
Professional regulation/role scope from a registration authority
The legal regulations that ERHNs need to adhere to are established by the Ministry of Health (2018). However, these regulations are general; neither of them is meant specifically to regulate the conduct of ERHNs. The Saudi Commission for Health Specialties (2012) is the authority that is concerned with the registration of all healthcare professionals in Saudi Arabia, including ERHN. The registration requirements typically focus on qualifications (education), the source of education (nurses who have studied in a variety of countries can be registered in Saudi Arabia) (Hibbert et al., 2017), training, and experience (Saudi Commission for Health Specialties [SCHS], 2014c). To become registered professionals, ERHNs need to consider the requirements of the SCHS (2014c), but the roles that this body singles out do not specifically include ERHN or any other nursing leadership role. In other words, the SCHS (2014c) does not specifically describe the role scope of ERHN.
However, Saudi Commission for Health Specialties [SCHS] (2014b) is also responsible for the development of the curricula for relevant education complete with specific learning objectives and expected outcomes, as well as related certification procedures. The curricula exist for different specialities, including that meant for the Emergency Medicine specialists (SCHS, 2014b). An analysis of the curriculum indicates that Emergency Medicine professionals in Saudi Arabia are expected to be well-trained in their field of practice, as well as collaboration and communication skills. Furthermore, management and health advocacy are incorporated into the curriculum. Therefore, it can be assumed that these key competencies are expected from Emergency Medicine professionals in Saudi Arabia, including ERHNs, and ERHNs need to adhere to these requirements.
Another document that regulates ERHN conduct in Saudi Arabia is the Code of Ethics developed by the Saudi Commission for Health Specialties [SCHS] (2014a). A code of ethics with specifications concerning professional conduct is provided by the Ministry of Health (2018) as well. The key aspects included in the code are those related to patients, community, colleagues, oneself, as well as the profession; some more specific considerations like the conduct in particular cases are also considered. The Islamic values and laws are viewed as one of the sources of medical ethics in the codes, which is a specific feature of Saudi settings (Al-Hazmi & Windsor, 2013). Codes of ethics are the documents that ERHNs need to adhere to, and that can be viewed as regulatory for ERHN, but they can also be treated as a detailed guide that can be employed by ERHNs in personal practice and during the management of disputes and conflict situations.
In summary, no regulations designed specifically for the role of ERHN were found in the documents presented by the Commission or the Ministry of Health (2018). Similarly, no direct definition of the role of ERHN or relevant scope of practice was found in the legislation, regulations, or other documents presented by the two bodies. Still, it can be suggested that the Commission and the Ministry of Health (2018) provide some general guidance on the topic, especially with respect to the skills, competencies, experience, and ethical conduct that constitute professionalism in ER settings, nursing, and outside of both. Thus, ERHN can use these materials as supplementary to define appropriate behaviour within the context of Saudi Arabia.
Workplace role expectations/potential job description
From what can be gathered from the materials presented by the Saudi Commission for Health Specialties [SCHS] (2015), as well as job descriptions available on the Internet, the workplace expectations of ERHN mostly coincide with the information described above. The list of specific ERHN responsibilities is very extensive; it includes both general statements (for instance, the maintenance of high standards of care or the promotion of safety culture) and more specific ones (for example, the development of a training needs assessment plan or the appraisal of performance). However, it can be described as the mixture of managerial and leadership activities, as well as some clinical ones. Furthermore, ERHNs are expected to ensure patient satisfaction and protection, which can be referred to the above-mentioned codes of ethics (SCHS, 2014a). Thus, the potential job description reflects all the major elements of the ERHN role and corresponds to the literature on this topic and related ones (Jonson et al., 2017; Kantanen et al., 2017; Zohar, Werber, Marom, Curlau, & Blondheim, 2017). Overall, this information supports the idea that ERHN role is complex and suggests that its practice coincides with this theory.
Skills/Performance
Given the numerous functions that an ERHN needs to perform, the skills required to ensure high-quality performance are similarly diverse and multiple. However, they can be classified into those pertinent to specific elements of the role, as well as some general ones that are warranted by the specifics of the settings. Indeed, for any nurse manager, clinical skills and knowledge are significant, which is why head nurses are required to be familiar with the specifics of the nursing activities pertinent to ER (Kantanen et al., 2017; Zhu & Wang, 2015). Similarly, head nurses are expected to exhibit the knowledge of their settings, which would enable them to effectively manage their processes and resources (Kantanen et al., 2017). This knowledge can be viewed as a requirement for successful management in ER; because of its significance, nurses are only promoted to ERHN after they have had several years of experience in ER (Zhu & Wang, 2015). Thus, the understanding of ER nursing, related processes, and the specifics of ER settings is a key competency for ERHN.
In turn, managerial skills are also particularly important for head nurses, including ERHN (Firouzkouhi et al., 2016; Jonson et al., 2017). They incorporate the ability to manage resources (including human resources), solve problems, make decisions, and so on (Dahshan et al., 2017; Firouzkouhi et al., 2016; Jonson et al., 2017; Ogbolu, Scrandis, & Fitzpatrick, 2017). A specific example of managerial skills is the resource and patient flow management, which are extremely important in ER settings due to the instances of major accidents that tend to result in multiple casualties, and this duty is predominantly taken by ERHNs (Jonson et al., 2017). Also, head nurses might need some skills pertinent to financial management in case they are involved in it, which is not an unusual practice (Bai et al., 2017). In general, managerial skills are rather numerous and diverse, but ERHN needs to master them to ensure the smooth functioning of their ER.
Leadership competencies are also a requirement for ERHN. They are similarly multifaceted but tend to be concerned with the skills related to human resource management and strategy (Kantanen et al., 2017). Some of the pertinent abilities include communication, conflict management, organisational culture improvement, and so on (Kantanen et al., 2017; Parizad et al., 2017; Wang, Anthony, & Kuo, 2016). An example that has a special significance for ER is teamwork (SCHS, 2015). For ERHN, the ability to work in a team and organise one should be considered one of the crucial skills (Grover, Porter, & Morphet, 2017), and it is directly connected to leadership abilities.
The skills that are not directly related to the three role elements but are still pertinent to ERHN can be mentioned as well. Due to the specifics of the settings, multitasking is particularly important for ER nurses (SCHS, 2015), especially ERHN. Similarly, the stressful nature of ER environment requires the ability to manage one’s stress, possibly, with the help of special techniques (Atakro et al., 2016; Parizad et al., 2017). Thus, the specifics of ER settings may have some implications for the required ERHN competencies that are not directly concerned with their specific roles but would still assist them in the process of performing their duties. Overall, the skills that ERHNs need to be familiar with are multiple, but they can be generalised by referring to the key elements of ERHN role.
Example Activities
Some of the example activities of head nurses that have been discussed in the recent literature apply to those typical for ERHN. For example, supervision is a major aspect of ERHN’s role, and it can be achieved, among other things, through interpersonal communication which offers an opportunity for policy clarification and behaviour modification (Zohar et al., 2017). These activities can be viewed as predominantly leadership-related. On the other hand, the budgeting is a managerial activity (Bai et al., 2017). The development of safety culture, which is exceptionally important for ER (Zhu & Wang, 2015), likely involves both managerial (development and enforcement of policies and processes) and leadership (vision communication) activities. Finally, an example which is concerned with every aspect of ERHN’s role can also be proposed. In particular, during the response to a major incident, ERHNs tend to take responsibility for managing the processes and activities, as well as patient flow, by exhibiting clinical, managerial, and leadership competencies (Jonson et al., 2017). Thus, the example activities of ERHNs can be both general and settings-specific and might require the application of skills pertinent to different elements of the role.
Role Benefits and Outcomes
For the Profession
Given that nursing can be viewed as a relatively young profession in Saudi Arabia (Al-Hazmi & Windsor, 2013; Hibbert et al., 2017), its advancement is particularly important. According to the Code of Ethics of Saudi healthcare professionals, the profession can benefit from the actions of ERHN, in particular, due to the maintenance of high standards and their improvement (SCHS, 2014a). From this perspective, the activities like continuous education, training of nurses, quality improvement efforts can be viewed as geared towards achieving beneficial outcomes for the profession. Similarly, the Commission sees ethical conduct as a form of supporting profession, which can be acknowledged. By contributing to the development of the profession and maintaining its positive image, ERHNs can achieve beneficial outcomes for it.
For Nurses
Given the fact that ERHN directly works with ER nurses, creating the environment in which they can successfully perform and empowering them to achieve better results, the outcomes of ERHN work for nurses should be highlighted as a separate category. Nowadays, there is enough evidence to state that ERHN can affect the job satisfaction and productivity of ER nurses through their managerial skills (Firouzkouhi et al., 2016). Moreover, the effective leadership of nurse managers may affect the commitment and job satisfaction of nurses while also empowering them to contribute to better organisational outcomes (Dahshan et al., 2017). Consequently, ERHN is a major factor in ensuring the quality of nursing and, therefore, care within their ER (Ogbolu et al., 2017). Supportive management and leadership are also predictive of decreased burnout (Dahshan et al., 2017; Firouzkouhi et al., 2016; Hunsaker, Chen, Maughan, & Heaston, 2015). Therefore, ERHNs are essential for nurse development and well-being, which affects the productivity of the latter and helps them to realise their potential.
For Clients
As it was mentioned, the key purpose of ERHNs is to maintain high standards of the quality of care and ensure the functioning of ER. Both these outcomes are beneficial for clients. Moreover, there is some evidence indicating that ERHNs can achieve said outcomes. The quality of care is dependent on the personnel, and head nurses are concerned with empowering ER nurses and developing an environment, in which they can achieve positive outcomes with respect to the quality of care (Dahshan et al., 2017; Ogbolu et al., 2017). Regarding the functioning aspect, ERHNs achieve it even in the conditions of scares resources and time shortage that follows the patient influx during major emergencies (Jonson et al., 2017). Thus, it can be suggested that ERHN role has an impact on the availability and quality of care, which implies positive outcomes for clients.
Research also highlights the significance of the nursing profession for the healthcare of Saudi Arabia and the growing need for its services (Hibbert et al., 2017). Therefore, it can be suggested that the role of ERHN is also particularly important for the clients in Saudi Arabia since it contributes to the management and improvement of a service that is in particularly high demand in the country. This factor emphasises the above-mentioned outcomes and demonstrates their significance.
Furthermore, some additional beneficial outcomes can be mentioned. Saudi ERHNs are ethically obliged to ensure the protection of patient rights (SCHS, 2014a). In connection with this requirement, there is also an ethical responsibility for ERHN to engage in advocacy (SCHS, 2014b). Thus, the activities of ERHNs that are not necessarily directly connected to their managerial or leadership duties are also beneficial for patients, as well as the entire community.
For ER and Organisations
Managerial and leadership positions are also very important from the organisational standpoint. For ER, which is an exceptionally high-risk unit with routine resource shortages, overcrowding, and reduced contact with patients, effective leadership and management are crucial for its functioning (Atakro et al., 2016; Jonson et al., 2017). It should also be mentioned that nurses are a very large group in healthcare, which is vital for its functioning (Bai et al., 2017). They can be viewed as the key human resource (Bai et al., 2017; Firouzkouhi et al., 2016). The fact that ERHNs play a major part in ensuring the effective work of this resource implies that their activities are very significant for ERs and healthcare institutions. Thus, organisational outcomes of ERHN work can also be mentioned as a separate category.
Regarding the specific documented organisational outcomes, head nurses are concerned with human resource management and development, which results in the improved effectiveness and performance and decreased turnovers (Dahshan et al., 2017; Firouzkouhi et al., 2016). Apart from that, improved efficiency, including cost-efficiency can be the result of effective management performed by head nurses (Bai et al., 2017). Finally, by providing leadership and management, ERHNs ensure the smooth functioning of ER, even in the aftermaths of major incidents (Jonson et al., 2017). Thus, there is some evidence indicating that the role of ERHN has beneficial outcomes for ER and healthcare organisations at large. In summary, ERHN is a role of great importance that tends to have favourable outcomes for multiple groups of stakeholders.
Role Experiences and Development Needs
The experiences of ER work appear to be connected to ERHNs needs. Some of ER specifics include increased risks and the requirement for quick decision-making and action (Atakro et al., 2016; Zhu & Wang, 2015). Consequently, the work at ER is particularly stressful (Atakro et al., 2016; SCHS, 2015; Parizad et al., 2017). The exposure to death can also be viewed as a stressor (Pegram, Grainger, Jones, & While, 2015). These stressors are amplified during major emergencies that typically require nurses to take the lead and manage a large influx of patients (Jonson et al., 2017). This specific feature of ER determines some of the conditions of ERHN operation.
Moreover, according to recent research, chaotic and highly stressful environments like ER are also conductive of negative workplace behaviours, including issues like incivility, bullying, and bickering (Parizad et al., 2017). This problem can affect the employees, patients, organisation, and even profession. The issue of violence towards ER specialists, including nurses, has been pointed out as well (Atakro et al., 2016; SCHS, 2015). Many of the conflicts are supposed to be managed by the head nurse, and violence, including verbal, can also affect the morale of the nurses or ERHN themselves (Atakro et al., 2016). Finally, ER work is rather time-consuming, which can influence work-and-life balance, as well as other aspects of social life (Atakro et al., 2016). Thus, the environment of ER poses some specific challenges that affect the experiences and needs of ERHN.
All the mentioned challenges are significant both for ERHNs and other ER who ERHNs need to lead and manage while taking into account these issues. It has been established that effective leadership can reduce burnout and turnover intent (Dahshan et al., 2017; Firouzkouhi et al., 2016; Hunsaker et al., 2015), which implies that effective leadership in ER settings is exceptionally important. As a leader, ERHN is also expected to manage conflicts (Atakro et al., 2016), including those related to the aggression towards nurses and within ER. Moreover, the development of a culture that would balance out the issues of ER and promote professional behaviour and ethical conduct is also a responsibility of leaders (Parizad et al., 2017). Thus, ERHNs need to be able to assist other nurses in dealing with the above-mentioned issues while also focusing on their own needs (SCHS, 2014a). Based on the above-presented information, the latter are connected to the outlined problems and include the need for stress management, protection measures, and work-and-life balance achievement. This aspect of ERHN functions also illustrates the complexity of the role.
Other experiences of ERHN have also been pointed out in the research. The issue of limited resources and high workloads is not uncommon in ER, especially given the mentioned large influxes of patients. This issue is reported by multiple resources on the topic (Atakro et al., 2016; Grover et al., 2017; Parizad et al., 2017; Pegram et al., 2015). The problem implies the need for the careful management of the available resources, which is one of the many functions of ERHN (Kantanen et al., 2017). The issue of insufficient training is also often mentioned by the articles that review ER and ERHN nurses’ perceptions (Atakro et al., 2016; Pegram et al., 2015). This problem is associated with increased occupational stress experienced by the professionals who feel underprepared for their roles (Pegram et al., 2015), which highlights the significance of addressing the issue. Consequently, it can be suggested that ERHN exhibit a need for continuous training, which should be considered in detail.
Indeed, professional development is crucial for the quality of service in ER (Morphet et al., 2016). Consequently, educational needs are one of the most significant development needs when ERHNs are concerned, particularly because continuing education is crucial for ER nurses (Zhu & Wang, 2015). Workplace training and education related to a variety of skills that ERHNs are supposed to exhibit ensures the quality of their work and, consequently, the quality of care provided by their ER.
There is some evidence to head nurse training having positive impacts on their performance. As can be seen from recent research, the training pertinent to managerial skills of ERHNs can result in improved job satisfaction in ER nurses, as well as the empowerment of ERHNs themselves (Firouzkouhi et al., 2016). Similarly, the development of the head nurses’ communication skills can assist in decreasing miscommunication and certain unhealthy tendencies (like nurse-blaming), which eventually results in improved teamwork and performance (Zohar et al., 2017). Bai et al. (2017) also report that by providing ERHNs with sufficient training on financial management, an institution can boost their performance in this respect. The ability to respond to emergencies can also be trained (Jonson et al., 2017). Thus, continuous training and education appear to be the key to equipping ERHNs with the skills required for their performance and that of the nurses of ERs.
Regarding the literature on the topic of the experiences of ERHN, head nurses, and ER, it appears that most relevant studies have been focusing on the negative aspects. This factor can be explained by the attempts to identify the needs of the nurses and the areas that can be improved. Thus, the present analysis of ERHN experiences can conclude that ERHN role is particularly complex, involves operation in a rather chaotic environment and problematic conditions, and, consequently, requires significant investment in training that would prepare ERHN to perform all the relevant tasks. This conclusion coincides with the above-presented information since the complexity of the role implies notable workload, and the specifics of the settings would be expected to be connected to some challenges.
Conclusion
Despite the lack of research on the topic, which may be attributed to its nascent nature, the role of ERHN in Saudi Arabia can be analysed with the help of modern literature and pertinent policies. ERHN is a very complex role that incorporates managerial, leadership, and clinical elements. Each of the mentioned elements requires specific skills and competencies; also, ERHNs exhibit more general skills that are not directly connected to the discussed role aspects but assist in carrying out related functions. The regulatory bodies of Saudi Arabia provide some general guidance for healthcare professionals, but they do not specifically focus on ERHN. At the same time, ERHNs have some rather unique needs that are connected to the specifics of their practice settings and the key ERHN functions. In particular, the stresses and challenges of ER, along with the complexities of ERHN role, seem to highlight the significance of continued education for ERHN. By equipping ERHN with the necessary skills and knowledge, an organisation can help them to achieve the outcomes that are beneficial for the profession, individual nurses, ER and healthcare institutions, patients, and the community.
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