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Nurse Leadership from Bedside to Boardroom

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Nurses add something quite unique to the experience of safe and patient-centered care, particularly during hospital stays. They are the ones most able to connect, communicate, and coordinate across multiple departments, professional opinions and voices, and the hurried schedules of a patient’s day. Advocating and designing care WITH the patient and family is a true skill set and cultural attribute that adds tremendously to a culture of safety and patient-centeredness but requires the most able leadership to build these bridges across the many professionals engaged in care. Building this culture is a leadership challenge and there is no one, in my experience, better able to make these changes than nursing leaders.
— Maureen Bisognano

There is increasing recognition that nurses must be involved as leaders and decision-makers throughout healthcare, not just at the bedside or within the nursing community. Nurses are executive leaders in health systems and hospitals, of course, and also in professional associations, accrediting organizations, businesses, government, and universities. Within the nursing community, many feel that the skill set nurses need for modern-day practice also makes them valuable contributors throughout health systems, especially in leadership positions. As Maureen Bisognano points out, the best nurses are accomplished envoys among different players and interests involved in direct patient care, which is a skill needed throughout organizations and businesses, not just in hospitals or healthcare.

To develop a sense of how nurse executives view their work, Patient Safety & Quality Healthcare (PSQH) conducted a brief, informal survey of nurses who hold leadership positions in a range of organizations. We asked them to describe their roles; the challenges they face, especially regarding safety and quality; and accomplishments in which they take special pride. We also asked about their views of the relationship between patient safety and safety in the workplace and the usefulness of social media in their work lives.

Their responses are not presented here as “typical” or to represent a cross-section of nurse executives; in reality, they represent a “tip of the iceberg” view. In their responses, these nurses draw from deep wells of expertise, experience, and commitment to improving healthcare delivery. They deserve copious thanks for the thoughtfulness of their responses as well as for their contributions to the healthcare community. When I sent the initial surveys to a small group by email, I was thrilled to see immediate engagement—quick responses, willingness to participate, and fluid networking as my survey was shared and forwarded to colleagues. These busy executives were generous with their time and clearly interested in advancing opportunities for nurse leaders to make satisfying, lasting contributions.

All Nurses Are Leaders
Laura Caramanica, immediate past president of AONE (American Organization of Nurse Executives), points out that while some nurses hold executive positions, all nurses are leaders. This is an important point, especially in the context of U.S. healthcare reform and other developments that intensify our need to empower all executives, staff members, clinicians, patients, and families to advance their practice (whatever it may be), improve their institutions, and support one another to provide the best experiences and outcomes possible.

In Fostering Nurse-Led Care (2013), Ives Erickson, Jones, Ditomassi, and other contributors observe that leadership is an element of practice for all nurses, “from the bedside to the boardroom.” To successfully engage their “inner leaders,” bedside nurses need strong leadership from other nurses. According to Burke, Gallivan, Tenney, and Whitney,

For nurses to find that “leadership within,” they need to be provided with high-quality management; a workplace where they can be mentored and can develop good working relationships with others within and beyond their discipline; and opportunities for the development of communication, team-building, and problem-solving skills, along with clinical nursing knowledge (Ives Erickson, p. 242).

In her response to our survey, Jeanette Ives Erickson (lead editor of Fostering Nurse-Led Care) describes a new initiative at Massachusetts General Hospital called Innovation Units, which promote relationship-based care and offer a new opportunity for clinical leadership, a position called the “attending nurse.” This new position and the Innovation Units are featured in a sidebar.

Nurse Executives Supporting Patient Safety
Whether patient safety is explicit in their titles or not, all of the nurse executives I contacted play important roles in patient safety for their organizations. Among those who are working in hospitals, there is a broad range of responsibilities for assuring the quality and safety of patient care by providing a supportive work environment that includes effective systems, current technology, and a culture of safety:

The chief nurse is responsible for creating a practice environment that allows staff to do and be at their best in every moment. Beyond the operational aspects of quality and safety, as the chief nurse executive, I am ultimately responsible for two broad drivers of quality and safety: our organizational culture and the systems that support staff in their practice.

Culture conveys the accepted norms of the practice environment—our collective beliefs and values—that determine how we think about and respond to quality and safety issues and/or events of any type. It is my responsibility to cultivate a just culture of relentless caring that is vigilant about quality and safety. We know from the literature that organizations that value teamwork and are transparent, proactive, and patient- and family-centered, will be among the safest. Everyone plays a role in quality and safety—the people who clean the floors on a patient care unit, deliver meals, volunteer, administer medications, even patients and families, everyone—plays a role in quality and safety.

We also know that errors and safety issues are rarely the result of poorly performing individuals, but are typically the result of a system flaw. As chief nurse, I am responsible for ensuring we provide staff with the optimum tools and technology, policies, procedures, and guidelines available, and that these work together to support their practice.
– Jeanette Ives Erickson

When asked to identify the most persistent challenge they face in safety improvement, most respondents mention culture, accountability, and communication. Barb Olson finds that communication is a prime challenge:

The degree of communication—frequency, quality and specificity—required by highly specialized healthcare professionals to ensure an appropriate plan of care that addresses each patient’s individual goals is in place and is executed is mind-boggling. With this in mind, I would have to say that building an effective, multi-modal communication infrastructure—one that places the patient’s voice at the center—is the most challenging deliverable in taming the complexity beast.

Olson also puts “managing complexity” on her list of challenges. Saying that she has “learned a great deal by studying other high-consequence industries—commercial aviation, for instance—in which intended outcomes are delivered in a reliable fashion,” Olson goes on to examine what is different about complexity in healthcare:

Lucian Leape called out the differences in complexity in an article (in a urology journal, I think) that I read a long time ago that has helped me think about the usefulness of these comparisons. One hundred and fifty passengers on a commercial flight, for example, share just a few common goals, namely getting from Point X to Point Y safely and on time. A skilled flight crew of five, gate agents, and air traffic controllers routinely execute familiar, well-designed processes, including mission-critical safety checks, that allow passengers to attain their common goals (“on time” being the only outcome in which unwelcome variability occurs on a regular basis). But patients in a hospital lack the homogeneity of commercial airline passengers. Some people come to the hospital for healing, others to improve functional abilities, and others seeking palliative care that will promote better quality at the end of life.

Kerri Scanlon comments that it can be a challenge to maintain individual accountability in a non-punitive environment and adds that the current fiscal climate is difficult:

I think there are two main challenges. One is the creation of a non-punitive “just” environment. We have to balance accountability and a non-punitive approach. We have improved consistently in this, but it remains a challenge. Second is the cost. Given the current healthcare reimbursement environment, it is a fine balance to continually institute technological solutions to improve patient safety. We are fortunate as a health system that we are able to afford significant investments in this area.

Anne Challis’s list of responsibilities gives a sense of the varied agenda she and many other nurse executives oversee:

[My] role focuses on constituency satisfaction status, core measure compliance, expense management, and the role of the clinicians and providers in case management activities. Each of these areas is significantly impactful in patient safety. As Kooker (2011) describes, increased nurse satisfaction leads to nurse retention, which leads to improved patient outcomes. The role of the local CNO in these activities is inherent in improvement, and the supportive role of the DCNO [division chief nursing officer] has shown to drive advances in patient safety outcomes.

Laura Caramanica mentions accountability and the importance of establishing a culture where staff members feel secure enough to discuss near misses openly:

Becoming a high reliability organization requires persistence in holding staff accountable to ensure that all safety goals are taken very seriously. I agree with those that say checklists are not enough. Staff must feel safe in speaking up and sharing a near miss without fear of losing their job or license.

Maureen Bisognano observes that frontline nurses traditionally take pride in and are rewarded for solving problems in real time. The wrong tray is delivered, the infusion pump is missing, medications aren’t available—nurses do whatever is necessary to fix these problems for the benefit of their patients. This habit of developing “workarounds” is now recognized as a significant breach in safety. Bisognano points to this as an opportunity for nurse leaders to help frontline nurses develop skills and empower themselves to improve safety for all:

Nurses get promoted because they’re excellent fixers. In many hospitals, nurses are working around broken processes all day long, actions that are viewed as heroic and admirable. In many cases, a nurse who calls out an error or system problem is viewed as a complainer. We need to shift from that fix-it mentality to one where nurses feel comfortable calling out issues as system problems. Nursing leaders can help staff develop skills and build improvement capability at the frontline that empowers nurses to be equally effective at solving individual problems and making systemic improvements.

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