At the annual holiday party, when the nursing department celebrated at a restaurant, staff members exchanged gifts at the end of the evening. The last gift, beautifully wrapped in silver paper with a large bow, went to the staff’s manager.

Everyone watched in silence as the manager unwrapped the gift and lifted out a large lump of coal.

The manager looked in confusion at the coal. Was this some kind of joke? No one was laughing. After a moment of silence, a staff nurse spoke up. "That’s what we thought you deserved," she said.

The manager threw the lump of coal on the table and ran from the restaurant crying.

The floodgates of communication had opened.

The staff was not surprised when the director of nursing called an emergency staff meeting the next day. "What is going on?" she asked.

The response came fast and furious. "She treats us like idiots." "She tells everyone they have to go through her to talk to us." "She doesn’t respect us." "She doesn’t support us." "She thinks she’s better than we are." "She never listens." "She doesn’t ask, she tells."

The manager, when it was her turn to speak, emphasized that she did care. She explained that often she felt as though she were sitting on a fence, torn between the administration and the nurses. She lived in fear of falling off the fence on either side.

She told the nurses that she respected them, but that ultimately she was responsible for their actions. She wanted to support them, but wasn’t sure what they wanted.

Fostering communication
Was the lump of coal the optimum method for the staff to make their wishes known? In a word, no, said Angela Thoburn, educator and owner of OMI Associates, a consulting company in Las Vegas.

"The nurses in this scenario need to ask themselves if they would like to be treated the way they treated their manager," she said.

"Rather than communicating directly with their manager and telling her the behaviors they did not like, they attacked her as a person."

Nurses shouldn’t wait for their managers to facilitate better communication, said Kathleen Sanford, vice president of nursing at Harrison Memorial Hospital and administrator at Harrison Silverdale in Bremerton, Wash.

"I expect nurses to begin conversations. We need to be advocates of our managers and ourselves, equally.

"If nurses have the perception that a manager is ineffective, they need to talk about it with the manager; they need to have an open conversation. That takes a certain type of maturity that a lot of people don’t have," Sanford said.

Managers and nurses need to initiate communication. A study recently published in the Journal of Nursing Administration that surveyed nurses in 12 hospitals in 1986 and again in 1998 reported in 1986 that 90 percent of nurses thought head nurses were good managers and were supportive of nurses.

The 1998 survey reported that only 70 percent of nurses held that same belief.

"Things have changed," Sanford said. "In the past, you worked side by side with your staff; you saw all three shifts and you knew everyone.

"Nurse managers have few hours in a day to nurture and hand-hold. People don’t talk face-to-face; they don’t walk down the hall to speak with someone. They just fire off an e-mail or post a note or printed e-mail on the bulletin board."

Root of the problem
The root of the communication problem, Sanford said, is that hospitals and administration expect more of nurses and managers than ever before.

"Today’s nurse managers have more than one unit to manage and may be responsible for as many as 100 to 150 people. They are involved in numerous task forces, meetings and regulation committees," Sanford said.

Many hospitals have removed middle management, which leaves fewer nurse managers to direct nurses, said Linda Aiken, Ph.D., RN, FAAN, professor at the University of Pennsylvania, School of Nursing. "The relationship between nurse managers and their ability to communicate with top management may be difficult. The problem with nurse managers is there are fewer of them than there used to be. They were the link to top management. Now the top is missing that link," Aiken said.

Although their numbers are inadequate, the first-line manager remains critical to the success of nursing care. "They [nurse managers] are the connection between the organization’s vision and how that vision is carried out," Thoburn said.

Investing in nurses
A good relationship between managers and staff is imperative for nurse retention. If administrators want to retain nurses, they need to invest in training and provide support for their front-line managers, Sanford said.

"Nurses are frequently promoted to management positions because they are excellent nurses," Thoburn said. "However, being an excellent nurse does not mean you will be an excellent manager.

"Nurses need to be taught additional communication skills when they are promoted to management. Positive and accountable communication is the glue that holds us together. When we abandon these responsibilities, we fall apart."

While some nurses lack the skill or management ability to be effective nurse managers, others merely need additional support and training. "If we don’t reward the good ones, we end up falling back on the bad ones," Sanford said.

But if nurses don’t have time to communicate because they are spread too thin, then training may be only part of the solution to solving management problems.

"Our management problems are all tied up with the nursing shortage. We’ve got to figure out how to have better staffing. That means smaller groups for nurse managers, too," Sanford said. Creating smaller groups to manage will cost more, of course.

The flip side, Sanford added, is that if nurses are not happy with their first-line manager, they will not remain loyal and turnover will be high. That’s expensive, too, she said. Research on turnover shows that nurses don’t leave hospitals––they leave their manager, Sanford said.

In the meantime, instead of a cruel gesture, creating sturdy paths of communication can offset poor relationships.