Being the head leader on a unit is a difficult task to manage. Everything flows in different directions and accountability always falls on the nurse manager. Healthcare organizations have come to recognize the importance of nursing input in fiscal planning, and nurse leader-managers in the 21st century are expected to be expert financial managers (Marquis & Huston, 2012). Having a proper balance in spending means using resources timely and wisely to be cost effective. Spending more does not necessarily mean quality care. Throughout the fiscal year, acuity in patient care fluctuates. Directing the assistant nurse managers and the relief charge nurses means working towards the same goals. Emphasis should always be to keep patients and staff satisfied. By doing that there needs to be a thorough plan for the business year.

There also needs to be contingency measures that handle unexpected situations such as staff shortages, spikes in acuity, or equipment needs. Evaluating needs and seeing first hand what goes on during a typical shift both day and night will help address certain issues. Assessing priorities and handling them in an orderly fashion based on highest need is essential. Looking at successes and failures by other units will help create a work plan designed to meet the needs of the floor. Most nursing staff has no knowledge into expenses on the floor’s budget. The more the staff understands the budgetary goals and the plans to carry out those goals, the more likely the goal attainment is (Marquis & Huston, 2012). By being prepare to handle different situations, it helps compact issues that occur throughout the year.

Expenses such as equipment request can be deferred until the next fiscal year. Priorities that take precedence would be to have proper staffing. Nurses often work in high stressful situations and deal with life and death on a constant basis. A survey of nurses in Pennsylvania showed that more than a third reported high levels of emotional exhaustion, a key component of burnout syndrome (Cimiotti, 2012).

With charge nurses requesting additional RN’s for each shift, their request should be accepted if there is funding in the budget to do so. This will alleviate some of the workload on the staff if the ratios are better in number. Expenses that can be addressed now but carried over to the next fiscal year would be the orthopedics conference in August. With some funds left in the budget, the registration fee, which is due now can be paid for and the remainder will be deferred to until the next fiscal year budget.

An area that should be invested is staff development. This would be used for continuing education in order for nurses to get preceptor training. This would ensure that the willing floor nurses are able to advance their roles on the floors as teachers and possible leaders of the unit. The preceptor’s relationship with the new nurse is key to the successful functioning and socialization of the nurse on the unit (Paternitti, 2006). While budget supplies remain strong with 4500 dollars left for the year, fluctuations in patient acuity can alter usage on a demand basis.

Factors that contributed to these inaccuracies primarily fell on nurse retention. Unfortunately these issues are somewhat predicted based on floor moral and acuity. Nurse turnover is a recurring problem for health care organizations (Jones & Gates, 2007). These could be controlled through staff feedback and management involvement with the routine nursing staff operations. By seeing first hand what the nurses have to deal with, this can open the eyes of the charge nurses to see what needs to be done to help improve staff delivery while not compromising patient care.

When dealing with patient acuity, a proper balance is needed to maintain the sanctity of the floor. Acuity has been increasingly used in an effort to control rising cost of patient care through tools designed to dictate appropriate staffing levels (Shaha & Bush, 1996). Nursing leaders have to deal with budgets and design them accordingly to meet the needs of the patient while maintaining proper patient ratios. Changes in healthcare reform are drastically causing nurses to deal with more work and responsibilities on a regular basis.

Once again, these changes can cause imbalances with staffing from nurse turnover. A way to maintain proper acuity according to classification systems is to assign each patient with a proper level. Assessing needs, workload, and complexity are tasks that will fall on the charge nurses from each shift. They will carry out this assignment every time a patient reaches the floor. A simple way to approach this would be to classify each patient with point system. The UK model rates patients from a one to four (Hurst et al., 2008). A patient with a score of one point would be a patient who is minimally dependent on the nurses. A patient who scores four points would classify as one that is completely dependent on the nursing staff. When making assignments for each shift, balancing the acuity according to the points system should help distribute the workload on each nurse.

Strategies in motivation would start off at the leadership level. A transformational leader is a manager who is committed, has a vision, and is able to empower others with this vision (Burns, 2003). This leader is committed for the long term and cares for the people during the change. For this situation, a transformational leader would communicate to the staff that this is not going to be an easy process but will work together in making it work. A transformational leader empowers others. This means that this leader would motivate and encourage he assistant managers to come up with ideas of how the floor changes can be done. Taking feedback from the staff and empowering them to new areas of innovation will help change the culture of the floor in a positive way. A transformational leader looks at the effects and identifies common values. This leader encompasses acting as a mediator and champion and exerting control over complex situations (McIntosh & Tolsen, 2009). One way to keep staff moral high in times of high acuity would be to know the floor point balances. If all nurses have more than one or two patients with a points classification system of a level four, then management should step assess the budget to see if a stat nurse or an extra nursing assistant would be feasible to help out the floor. If that is not possible then even something as simple as a free lunch can go a long way.

With the government becoming strict on hospital reimbursement, quality patient care has become the constant initiative towards meeting goals. Signed in 2010 by the president, the Affordable Care Act went into effect on June of 2012. Section 3014 of the Affordable Care Act focuses on quality measures for patient improvement while in the hospital. Aligned with the Centers for Medicare and Medicaid Services, this ensures that hospitals will meet the goals with establishing their core measures. Under HCAPS scores, departments are graded on the work given and the patients that were discharged provide feedback on their hospital stay. The categories graded are hospital cleanliness, staff responsiveness, environmental noise, physician communication, nurse communication, medication/discharge information, pain control, and willingness to recommend.

A structure that is implemented as a tool to improve consumer satisfaction around the country is hourly rounding on patients. This initiative tool was designed to meet the needs of patients on a constant basis with around the clock attention. Nurses involved in hourly rounding protocol are finding their shifts less stressful, their time more productive, and their patient safety and satisfaction scores hitting all-time highs (Leighty, 2006). This would not only fall on the nurses to fulfill but also on the unit manager, charge nurses, therapists, case managers, and even the doctors to perform. The phrase, “Is there anything else I can do for you before I go?” should become a common phrase within the floor itself. Another tool that can be implemented on the floor would be daily care plans. These care plans can have a list of a patient’s up to date hospital status such as medication list, doctors on their case, therapy, and procedures. These can be distributed by the nurses with a brief explanation of their care and answer any questions the patient or family may have including education. If a patient is going to get discharged within the next few days, a quick survey to the patient or family can be passed out. The goal is to answer any issues or concerns while the patient is still the hospital. By meeting these goals before discharge, it hopefully will reflect upon patient surveys scores that are sent out after they are home.Those scores in each category are graded from a zero to one hundred percent and are calculated monthly on a year round basis to see which areas need improvement. The overall goal is maintain a ninety and above in all categories. Our system has become a pay for performance system. The work the nurses do in regards to patient care reflect back on the facility and its budget if satisfaction is not met.

By assessing the needs on the floor based on priority, the budget requests will be met in all areas. Personnel and overtime accounted for areas of the budget that were inaccurate. Accountability for why these areas were inaccurate was partially due to workload and patient acuity leading to nurse turnover and a decrease in patient care. This cycle then puts remaining floor nurses to work overtime causing the overtime budget to decrease. Patient acuity can be distributed using a point system assigned to each patient. By assessing each patient and assigning the proper points to each nurse, it will hopefully distribute the workload to the staff as a whole. Having a transactional leader who is open and receptive to the staff will open a forum of communication on the floor. Answering questions and taking feedback will hopefully create an environment that empower each employee to take initiative and create ideas that will help the floor and improve patient care delivery. Getting staff involved to help improve patient satisfaction will reflect on survey scores that ultimately will dictate hospital reimbursement. Promoting hourly rounding and distributing care plans on the unit should become a structure used on a daily basis as quality measures of improving hospital stay. By fulfilling all these tasks, the unit manager should have a strong cohesive unit aimed at retaining staff and achieving the overall goal of promoting quality patient care.



Beck, D. (2009). Patient Acuity Systems promote care. Nursing News, 33(2), 15.

Burns, J. M. (2003). Transforming leadership. New York, NY: Grove/Atlantic, Inc.

Cansador, K. (2013).eHow money The Average Salary of an RN in Florida Retrieved from: florida.html

Cimiotti, J. (2012). Centers for Disease Control and Prevention: Nurse Burnout and HAI’S: A Solution to a Common Problem retrieved from: (2013) Read the Law. The Affordable Care Act Section by SectionRetrieved from:

Hurst, K., Smith, A., Casey, A., Fenton, K., Scholefield, H., & Smith, S. (2008).Calculating staffing requirements. Nursing Management-UK, 15(4), 26-34

Jones, C., Gates, M., (2007) “The Costs and Benefits of Nurse Turnover: A Business Case for Nurse Retention” OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 3, Manuscript 4.

Leighty J. (2006). Studer Group You Called? Hourly Rounding Cuts Call Lights Retrieved from:

Marquis, B.L., & Huston, C. (2012). Leadership roles and management functions in nursing: Theory and application (7th ed.) Philadelphia, PA: Lippincott, Williams & Wilkins.

McIntosh, J., & Tolson, D. (2009, January). Leadership as part of the nurse consultant r ole: Banging the drum for patient care. Journal of Clinical Nursing, 18(2), 219– 227.

Paternittie T. (2006). The Successful Nurse Preceptor retrieved from:

Shaha, S., & Bush, C. (1996). Fixing acuity: a professional approach to patient classification and staffing. Nursing Economic$, 14(6), 346-356.