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Nursing Leadership

Nursing Leadership

Strong leadership will be required to realize the vision of a transformed healthcare system, in addition to changes in nursing practice and education, as discussed in Chapters 3 and 4, respectively. Although the public is not accustomed to seeing nurses as leaders, and not all nurses enter the profession to become leaders, all nurses must be leaders in the design, implementation, and evaluation of, as well as advocacy for, the ongoing system reforms that will be required. Nurses will also need leadership skills and competencies to work as full partners with physicians and other health professionals in redesign and reform efforts throughout the healthcare system. Nursing research and practice must continue to identify and develop evidence-based care improvements, which must be tested and adopted through policy changes throughout the healthcare system. Nursing leaders must translate new research findings into the practice environment, nursing education, practice, and policy.

Being a full partner spans all levels of the nursing profession. It necessitates applying leadership skills and competencies within the work and collaborating with other health professionals. Being a full partner in a care setting entails identifying problems and areas of waste, developing and implementing an improvement plan, tracking progress over time, and making necessary adjustments to achieve established goals. As strong patient advocates, nurses must be involved in decisions about how to improve care delivery.

Being a full partner has broader implications in the realm of health policy. Nurses must see the policy as something they can shape and develop rather than something that happens to them to be effective in reconceptualized roles and to be seen and accepted as leaders, whether at the local organizational level or the national level. They must be able to speak policy language, participate effectively in the political process, and work as a team. Nurses should have a say in health policy decisions and be involved in health care reform implementation efforts. Nurses should also participate actively in advisory committees, commissions, and boards where policy decisions are made to advance health systems and improve patient care. To help realize these improvements, nurses must form new partnerships with other clinicians, business owners, philanthropists, elected officials, and the general public.
This chapter focuses on key message #3 from Chapter 1: Nurses should be full partners in redesigning health care in the United States alongside physicians and other health professionals. The chapter begins by considering the new leadership style that is required. It then issues a challenge for nurses to respond to. The third section describes three avenues for responding to that call: leadership programs for nurses, mentorship, and participation in the policy-making process. The chapter then issues a call for new collaborations to fully realize nurses’ potential as leaders in the healthcare system. The final section summarizes the committee’s findings on transforming leadership in the nursing profession.

The healthcare system’s nurses, physicians, patients, and others are increasingly interdependent. Every day, problems arise that need more than simple or singular solutions. Leaders who give orders and expect them to be followed will fail in this environment. What is required is a leadership style that involves working with others as full partners in an atmosphere of mutual respect and collaboration. This leadership style has been linked to better patient outcomes, fewer medical errors, and lower staff turnover (Gardner, 2005; Joint Commission, 2008; Pearson et al., 2007). It may also reduce workplace bullying and disruptive behaviour, which is still prevalent in the healthcare industry (Joint Commission, 2008; Olender-Russo, 2009; Rosenstein & O’Daniel, 2008). Although the benefits of collaboration among health professionals have been repeatedly documented in terms of improved patient outcomes, shorter hospital stays, cost savings, increased job satisfaction and retention among nurses, and improved teamwork, interprofessional collaboration is only sometimes the norm in the health care field. It will be challenging to change this culture.

The required new leadership style flows in all directions and at all levels. Everyone must involve colleagues, subordinates, and executives from the bedside to the boardroom to identify and achieve common goals (Bradford & Cohen, 1998). All members of the healthcare team must work together to manage their practice. Physicians, nurses, and other health professionals must collaborate to break down hierarchical silos and hold each other accountable for quality improvement and reducing preventable adverse events and medication errors. All must adapt to the ever-changing dynamics of the healthcare system.

Competencies for Leadership
Nurses require strong leadership skills to contribute to patient safety and care quality. However, their history as a female-dominated profession may make it easier for policymakers, other health professionals, and the general public to view nurses as “functional doers”—those who carry out the instructions of others—rather than “thoughtful strategists”—those who make informed decisions and take independent actions based on education, evidence, and experience. “Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions,” a 2009 Gallup poll of more than 1,500 national opinion leaders1, identified nurses as “one of the most trusted sources of health information” (see Box 5-1). (RWJF, 2010a). The Gallup poll also identified nurses as the health professionals who should have more influence than they do now in the critical areas of patient care quality and safety. Major obstacles, according to the leaders polled, prevent nurses from having a more significant influence on health policy decision making. These findings have significant implications for front-line nurses with critical knowledge and awareness of the patient, family, and community but do not speak up as frequently as they should.

Box Icon BOX 5-1 \sResults of Gallup Poll “Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions”. Opinion leaders rank doctors and nurses first and second on a list of trusted sources for health and wellness information (more…)

Nurses must possess two critical competencies to be more effective leaders and full partners: a general set that can serve as the foundation for any leadership opportunity and a specific set tailored to a specific context, time, and place. The former set includes, among other things, knowledge of the care delivery system, teamwork, effective collaboration within and across disciplines, the fundamentals of ethical care, how to be an effective patient advocate, theories of innovation, and the foundations for quality and safety improvement. The American Association of Colleges of Nursing also recommends these competencies for baccalaureate programs (AACN, 2008). The National League for Nursing and the National League for Nursing Accrediting Commission are revising their leadership competencies to reflect similar principles. Learning how to be a full partner in a health team where members from various professions hold each other accountable for improving quality and reducing preventable adverse events, and medication errors are examples of more specific competencies. Additionally, nurses pursuing entrepreneurial and business development opportunities must know economics, market forces, regulatory frameworks, and financing policy.

Leadership in a Collaborative Setting
As mentioned in Chapter 1, an expanding body of research has begun to highlight the potential for collaboration among diverse teams of individuals from various professions (Paulus & Nijstad, 2003; Pisano & Verganti, 2008; Singh & Fleming, 2010; Wuchty et al., 2007). According to practitioners and organizational leaders alike, collaboration is a critical strategy for improving problem-solving and achieving innovation in health care. Collaboration among health professionals is defined by two nursing researchers who have studied it as

A communication process that fosters innovation and advanced problem solving among people from various disciplines, organizational ranks, or institutional settings [and who] band together for advanced problem solving [in order to] discern innovative solutions regardless of discipline, rank, or institutional affiliation [and to] enact change based on a higher standard of care or organizational outcomes]. (2004) Kinnaman and Bleich

Much of what is referred to as collaboration is more likely cooperation or care coordination. According to Katzenbach and Smith (1993), genuinely collaborative teams differ from high-functioning groups with a defined leader and a set direction but lack the dynamics of true teamwork. The case study in Box 5-2 demonstrates how critical it is for health professionals to collaborate to provide accessible and patient-centred care.

BOX 5-2 Case Study: Arkansas Aging Initiative. A statewide program employs interprofessional teams to improve access to care for Arkansans over 65. Bonnie Sturgeon was an independent 80-year-old when shortness of breath started to slow her down in 2005. She had been (more…)

Every Level of Leadership
Nurse leadership is required at all levels and in all settings. Although collaboration is generally a noble goal, there are times when nurses must act as advocates with a single voice in order to provide exceptional patient and family care. At the same time, effective leadership necessitates the recognition of situations in which it is essential to mediate, collaborate, or follow others in leadership roles. Nurses must understand that their leadership skills are just as essential as their technical ability to provide safe and effective care at the bedside. They must take the lead in improving front-line work processes, developing new integrated practice models, and collaborating with others, from organizational policymakers to state legislators, to craft practice policy and legislation that allows nurses to work to their full potential, leading curriculum changes to prepare the nursing workforce to meet community and patient needs, translating and applying research findings into practice, and developing functional models of care.

Leadership in care delivery is crucial in community and home settings, where nurses work with patients and families more autonomously than in acute care settings. Nurses are a direct link between patients, caregivers, and other members of the healthcare team in the community and home settings. Other healthcare team members may need more time, expertise, or firsthand knowledge of the patient’s home environment and circumstances to understand and respond to patient and family needs. A neurologist, for example, may be unable to assist a caregiver of an Alzheimer’s patient in understanding or reducing excessive spending habits, and a surgeon may be unable to advise a caregiver on ostomy care—roles nurses are perfectly positioned to fill. Leadership in these situations sometimes necessitates nurses being assertive and speaking up for patients and their families to ensure that their needs are communicated and adequately met.

Box 5-3 describes a nurse who realized that becoming an agent of change was equally crucial in her job after believing that being a practical nurse was all about honing her nursing skills and competencies.

BOX 5-3 is a box icon.
Connie Hill is a nurse. A Nurse Leader Takes Acute Care Nursing Outside of the Hospital Walls Connie Hill, MSN, RN, reviewed the chart of a child who had been on a ventilator during a meeting at Children’s Memorial Hospital in Chicago in 2002. (more…)

Leadership does not happen in a vacuum, either socially or politically. According to Bennis and Nanus (2003), the fast pace of change can only be managed if it is accompanied by leaders who can track the context of the “social architecture” to sustain and implement innovative ideas. Developing innovative care models at the bedside and in the community, as well as pursuing a seat on a policy-making body or boardroom, necessitates nurse leaders developing ideas, approaching management, and courageously making decisions within the political, economic, and social contexts that will make their solutions natural and sustainable. A shift in how nurses view their responsibility to those they care for is required; they must see themselves as full partners with other health professionals, and practice and education settings must socialize and educate them accordingly.

Mentoring others is an integral part of this socialization process. More experienced nurses must take the time to show newer and less experienced nurses how to be exceptional at the bedside, in the boardroom, and everywhere in between. Chat rooms, Facebook, and even blogs can be used to supplement the mentoring role.

Understanding how leadership and practice produce change over time is critical to working within social architecture. There are numerous examples in nursing history of the impact of nursing leadership on system changes and patient care improvements. Nurse Elizabeth Carnegie led the fight for racial integration of nursing in Florida by example and through her extraordinary character and organizational skills in the late 1940s and early 1950s. Her efforts to integrate the nursing profession were motivated by a sense of social justice for the profession and the care of African American citizens who lacked access to a skilled workforce and adequate healthcare services. In Florida, Dorothy Smith, the first dean of the new University of Florida College of Nursing, developed nursing practice models that brought nursing faculty into hospitals in a joint nursing service in the late 1950s. Students had role models in their learning experiences, and staff nurses were empowered to improve patient care. This system gave birth to the patient kardex and the unit management system, which relieved nurses of the constant search for supplies, which kept them away from the bedside. Nursing research by Neville Strumpf and Lois Evans in the 1980s highlighted the dangers of using restraints on frail elders (Evans & Strumpf, 1989; Strumpf & Evans, 1988). Their efforts to put their findings into practice transformed nursing practice in nursing homes, hospitals, and other facilities by focusing nursing care on preventing falls and other injuries associated with restraint use. They led to state and federal legislation that reduced restraints on frail elders.
Nursing Leadership
Nurses have also led efforts to improve health and access to care through for-profit ventures. Ruth Lubic, for example, established the country’s first free-standing birth centre in New York City in 1975. She founded the Family Health and Birth Center in Washington, DC, in 2000 to serve underserved communities (see Box 2-2 in Chapter 2). Over the years, her efforts have improved the care of thousands of women. There are numerous other examples of nurse entrepreneurs. A nurse entrepreneur network2 offers networking, education and training, and coaching to nurses looking to enter the marketplace and business.
Prepare a 10-15 slide PowerPoint presentation, with speaker notes, that examines the significance of an organization’s culture and values. For the presentation of your PowerPoint, use Loom to create a voice-over or a video. Refer to the Topic Materials for additional guidance on recording your presentation with Loom. Include an additional slide for the Loom link at the beginning, and an additional slide for References at the end.

Outline the purpose of an organization’s mission, vision, and values.
Explain why an organization’s mission, vision, and values are significant to nurse engagement and patient outcomes.
Explain what factors lead to conflict in professional practice. Describe how organizational values and culture can influence the way conflict is addressed.
Discuss effective strategies for resolving workplace conflict and encouraging interprofessional collaboration.
Discuss how organizational needs and the culture of health care influence organizational outcomes. Describe how these relate to health promotion and disease prevention from a community health perspective.
You are required to cite a minimum of three sources to complete this assignment. Sources must be appropriate for the assignment and relevant to nursing practice.

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