Read section 5 Transforming Leadership of the IOM report related to this Key Message #3: ‘Nurses should be full partners, with physicians and other health care professionals, in redesigni

5Transforming Leadership

Key Message #3 : Nurses should be full partners,with physicians and other health professionals, inredesigning health care in the United States.

Strong leadership is critical if the vision of a transformed health care system is to be realized. Yet not all nurses begin their career with thoughts of becoming a leader. The nursing profession must produce leaders throughout the health care system, from the bedside to the boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.

In addition to changes in nursing practice and education, discussed in Chapters  3  and  4 , respectively, strong leadership will be required to realize the vision of a transformed health care system. Although the public is not used to viewing nurses as leaders, and not all nurses begin their career with thoughts of becoming a leader, all nurses must be leaders in the design, implementation, and evaluation of, as well as advocacy for, the ongoing reforms to the system that will be needed. Additionally, nurses will need leadership skills and competencies to act as full partners with physicians and other health professionals in redesign and reform efforts across the health care system. Nursing research and practice must continue to identify and develop evidence-based improvements to care, and these improvements must be tested and adopted through policy changes across the health care system. Nursing leaders must translate new research findings to the practice environment and into nursing education and from nursing education into practice and policy.

Being a full partner transcends all levels of the nursing profession and requires leadership skills and competencies that must be applied both within the profession and in collaboration with other health professionals. In care environments, being a full partner involves taking responsibility for identifying problems and areas of waste, devising and implementing a plan for improvement, tracking improvement over time, and making necessary adjustments to realize established goals. Serving as strong patient advocates, nurses must be involved in decision making about how to improve the delivery of care.

Being a full partner translates more broadly to the health policy arena. To be effective in reconceptualized roles and to be seen and accepted as leaders, nurses must see policy as something they can shape and develop rather than something that happens to them, whether at the local organizational level or the national level. They must speak the language of policy and engage in the political process effectively, and work cohesively as a profession. Nurses should have a voice in health policy decision making, as well as being engaged in implementation efforts related to health care reform. Nurses also should serve actively on advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care. Nurses must build new partnerships with other clinicians, business owners, philanthropists, elected officials, and the public to help realize these improvements.

This chapter focuses on  key message #3  set forth in  Chapter 1 : Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. The chapter begins by considering the new style of leadership that is needed. It then issues a call to nurses to respond to the challenge. The third section describes three avenues—leadership programs for nurses, mentorship, and involvement in the policy-making process—through which that call can be answered. The chapter then issues a call for new partnerships to tap the full potential of nurses to serve as leaders in the health care system. The final section presents the committee’s conclusions regarding the need to transform leadership in the nursing profession.

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A NEW STYLE OF LEADERSHIP

Those involved in the health care system—nurses, physicians, patients, and others—play increasingly interdependent roles. Problems arise every day that do not have easy or singular solutions. Leaders who merely give directions and expect them to be followed will not succeed in this environment. What is needed is a style of leadership that involves working with others as full partners in a context of mutual respect and collaboration. This leadership style has been associated with improved patient outcomes, a reduction in medical errors, and less staff turnover (Gardner, 2005; Joint Commission, 2008; Pearson et al., 2007). It may also reduce the amount of workplace bullying and disruptive behavior, which remains a problem in the health care field (Joint Commission, 2008; Olender-Russo, 2009; Rosenstein and O’Daniel, 2008). Yet while the benefits of collaboration among health professionals have repeatedly been documented with respect to improved patient outcomes, reduced lengths of hospital stay, cost savings, increased job satisfaction and retention among nurses, and improved teamwork, interprofessional collaboration frequently is not the norm in the health care field. Changing this culture will not be easy.

The new style of leadership that is needed flows in all directions at all levels. Everyone from the bedside to the boardroom must engage colleagues, subordinates, and executives so that together they can identify and achieve common goals (Bradford and Cohen, 1998). All members of the health care team must share in the collaborative management of their practice. Physicians, nurses, and other health professionals must work together to break down the walls of hierarchal silos and hold each other accountable for improving quality and decreasing preventable adverse events and medication errors. All must display the capacity to adapt to the continually evolving dynamics of the health care system.

Leadership Competencies

Nurses at all levels need strong leadership skills to contribute to patient safety and quality of care. Yet their history as a profession dominated by females can make it easier for policy makers, other health professionals, and the public to view nurses as “functional doers”—those who carry out the instructions of others—rather than “thoughtful strategists”—those who are informed decision makers and whose independent actions are based on education, evidence, and experience. A 2009 Gallup poll of more than 1,500 national opinion leaders, 1  “Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions,” 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 that should have greater influence than they currently do in the critical areas of quality of patient care and safety. The leaders surveyed believed that major obstacles prevent nurses from being more influential in health policy decision making. These findings have crucial implications for front-line nurses, who possess critical knowledge and awareness of the patient, family, and community but do not speak up as often as they should.

BOX 5-1

Results of Gallup Poll “Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions”. Opinion leaders rate doctors and nurses first and second among a list of options for trusted information about health and health  (more…)

To be more effective leaders and full partners, nurses need to possess two critical sets of competencies: a common set that can serve as the foundation for any leadership opportunity and a more specific set tailored to a particular context, time, and place. The former set includes, among others, knowledge of the care delivery system, how to work in teams, how to collaborate effectively within and across disciplines, the basic tenets of ethical care, how to be an effective patient advocate, theories of innovation, and the foundations for quality and safety improvement. These competencies also are recommended by the American Association of Colleges of Nursing as essential for baccalaureate programs (AACN, 2008). Leadership competencies recommended by the National League for Nursing and National League for Nursing Accrediting Commission are being revised to reflect similar principles. More specific competencies might include learning how to be a full partner in a health team in which members from various professions hold each other accountable for improving quality and decreasing preventable adverse events and medication errors. Additionally, nurses who are interested in pursuing entrepreneurial and business development opportunities need competencies in such areas as economics and market forces, regulatory frameworks, and financing policy.

Leadership in a Collaborative Environment

As noted in  Chapter 1 , a growing body of research has begun to highlight the potential for collaboration among teams of diverse individuals from different professions (Paulus and Nijstad, 2003; Pisano and Verganti, 2008; Singh and Fleming, 2010; Wuchty et al., 2007). Practitioners and organizational leaders alike have declared that collaboration is a key strategy for improving problem solving and achieving innovation in health care. Two nursing researchers who have studied collaboration among health professionals define it as

a communication process that fosters innovation and advanced problem solving among people who are of different disciplines, organizational ranks, or institutional settings [and who] band together for advanced problem solving [in order to] discern innovative solutions without regard to discipline, rank, or institutional affiliation [and to] enact change based on a higher standard of care or organizational outcomes. (Kinnaman and Bleich, 2004)

Much of what is called collaboration is more likely cooperation or coordination of care. Katzenbach and Smith (1993) argue that truly collaborative teams differ from high-functioning groups that have a defined leader and a set direction, but in which the dynamics of true teamwork are absent. The case study presented in  Box 5-2  illustrates just how important it is for health professionals to work in teams to ensure that care is accessible and patient centered.

BOX 5-2

Case Study: Arkansas Aging Initiative.  A Statewide Program Uses Interprofessional Teams to Improve Access to Care for Older Arkansans  Bonnie Sturgeon was an independent 80-year-old in 2005 when shortness of breath began to slow her down. She had been  (more…)

Leadership at Every Level

Leadership from nurses is needed at every level and across all settings. Although collaboration is generally a laudable goal, there are many times when nurses, for the sake of delivering exceptional patient and family care, must step into an advocate role with a singular voice. At the same time, effective leadership also requires recognition of situations in which it is more important to mediate, collaborate, or follow others who are acting in leadership roles. Nurses must understand that their leadership is as important to providing quality care as is their technical ability to deliver care at the bedside in a safe and effective manner. They must lead in improving work processes on the front lines; creating new integrated practice models; working with others, from organizational policy makers to state legislators, to craft practice policy and legislation that allows nurses to work to their fullest capacity; 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; and serving on institutional and policy-making boards where critical decisions affecting patients are made.

Leadership in care delivery is particularly important in community and home settings where nurses work more autonomously with patients and families than they do in the acute care setting. In community and home settings, nurses provide a direct link connecting patients, their caregivers, and other members of the health care team. Other members of the health care team may not have the time, expertise, or first-hand experience with the patient’s home environment and circumstances to understand and respond to patient and family needs. For example, a neurologist may not be able to help a caregiver of an Alzheimer’s patient understand or curtail excessive spending habits, or a surgeon may not be able to offer advice to a caregiver on ostomy care—roles that nurses are perfectly positioned to assume. Leadership in these situations sometimes requires nurses to be assertive and to have a strong voice in advocating for patients and their families to ensure that their needs are communicated and adequately met.

Box 5-3  describes a nurse who evolved over the course of her career from thinking that being an effective nurse was all about honing her nursing skills and competencies to realize that becoming an agent of change was an equally important part of her job.

BOX 5-3

Nurse Profile: Connie Hill.  A Nurse Leader Extends Acute Care Nursing Beyond the Hospital Walls  It was at a 2002 meeting at Children’s Memorial Hospital in Chicago that Connie Hill, MSN, RN, reviewed the chart of a child who had been on a ventilator  (more…)

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A CALL FOR NURSES TO LEAD

Leadership does not occur in a social or political vacuum. As Bennis and Nanus (2003) note, the fast pace of change can be managed only if it is accompanied by leaders who can track the context of the “social architecture” to sustain and implement innovative ideas. Creating innovative care models at the bedside and in the community or taking the opportunity to fill a seat in a policy-making body or boardroom requires nurse leaders to develop ideas; approach management; and courageously make decisions within the political, economic, and social context that will make their solutions real and sustainable. A shift must take place in how nurses view their responsibility to those they care for; they must see themselves as full partners with other health professionals, and practice and education environments must socialize and educate them accordingly.

An important aspect of this socialization is mentoring others along the way. More experienced nurses must take the time to show those who are new and less experienced the most effective ways of being an exceptional nurse at the bedside, in the boardroom, and everywhere between. Technology such as chat rooms, Facebook, and even blogs can be used to support the mentoring role.

A crucial part of working within the social architecture is understanding how leadership and practice produce change over time. The nursing profession’s history includes many examples of the effect of nursing leadership on changes in systems and improvements in patient care. In the late 1940s and early 1950s, nurse Elizabeth Carnegie led the fight for the racial integration of nursing in Florida by example and through her extraordinary character and organizational skills. Her efforts to integrate the nursing profession were based in her sense of social justice not just for the profession, but also for the care of African American citizens who had little access to a workforce that was highly skilled or provided adequate access to health care services. Also in Florida, in the late 1950s, Dorothy Smith, the first dean of the new University of Florida College of Nursing, developed nursing practice models that brought nursing faculty into the hospital in a joint nursing service. Students thereby had role models in their learning experiences, and staff nurses had the authority to improve patient care. From this system came the patient kardex and the unit manager system that freed nurses from the constant search for supplies that took them away from the bedside. In the 1980s, nursing research by Neville Strumpf and Lois Evans highlighted the danger of using restraints on frail elders (Evans and Strumpf, 1989; Strumpf and Evans, 1988). Their efforts to translate their findings into practice revolutionized nursing practice in nursing homes, hospitals, and other facilities by focusing nursing care on preventing falls and other injuries related to restraint use, and led to state and federal legislation that resulted in reducing the use of restraints on frail elders.

Nurses also have also led efforts to improve health and access to care through entrepreneurial endeavors. For example, Ruth Lubic founded the first free-standing birth center in the country in 1975 in New York City. In 2000, she opened the Family Health and Birth Center in Washington, DC, which provides care to underserved communities (see  Box 2-2  in  Chapter 2 ). Her efforts have improved the care of thousands of women over the years. There are many other examples of nurse entrepreneurs, and a nurse entrepreneur network 2  exists that provides networking, education and training, and coaching for nurses seeking to enter the marketplace and business.

Will Student Nurses Hear the Call?

Leadership skills must be learned and mastered over time. Nonetheless, it is important to obtain a basic grasp of those skills as early as possible—starting in school (see  Chapter 4 ). Nursing educators must give their students the most relevant knowledge and practice opportunities to equip them for their profession, while instilling in them a desire and expectation for new learning in the years to come. Regardless of the basic degree with which a nurse enters the profession, faculty should feel obligated to show students the way to their first or next career placement, as well as to their next degree and continuous learning opportunities.

Moreover, students should not wait for graduation to exercise their potential for leadership. In Georgia, for example, health students came together in 2001 under the banner “Lead or Be Led” to create a student-led, interprofessional nonprofit organization that “seeks to make being active in the health community a professional habit.” Named Health Students Taking Action Together (Health-STAT), the group continues to offer workshops in political advocacy, media training, networking, and fundraising. Its annual leadership symposium convenes medical, nursing, public health, and other students statewide to learn about health issues facing the state and work together on developing potential solutions (HealthSTAT, 2010). The National Student Nurses Association (NSNA), initiated in 1998, offers an online Leadership University that allows students to enhance their capacity for leadership through several avenues, such as earning academic credit for participating in the university’s leadership activities and discussing leadership issues with faculty. Students work in cooperative relationships with other students from various disciplines, faculty, community organizations, and the public (Janetti, 2003).  Box 5-4  profiles two student leaders, one of whom eventu ally became NSNA president; both represent as well the growing diversity of the nursing profession, a crucial need if the profession is to rise to the challenge of helping to transform the health care system (see  Chapter 4 ).

BOX 5-4

Nurse Profile: Kenya D. Haney and Billy A. Caceres.  Building Diversity in Nursing, One Student at a Time  Despite improvements to thedemographic make up of the nursing workforce in recent decades, the workforce remains predominantly white, female, and  (more…)

Looking to the future, nurse leaders will need the skills and knowledge to understand and anticipate population trends. Formal preparation of student nurses may need to go beyond what has traditionally been considered nursing education. To this end, a growing number of schools offer dual undergraduate degrees in partnership with the university’s business or engineering school for nurses interested in starting their own business or developing more useful technology. Graduate programs offering dual degree programs with schools of business, public health, law, design, or communications take this idea one step further to equip students with an interest in administrative, philanthropic, regulatory, or policy-making positions with greater competencies in management, finance, communication, system design, or scope-of-practice regulations from the start of their careers.

Will Front-Line Nurses Hear the Call?

Given their direct and sustained contact with patients, front-line nurses, along with their unit or clinic managers, are uniquely positioned to design new models of care to improve quality, efficiency, and safety. Tapping that potential will require developing a new workplace culture that encourages and supports leaders at the point of care (whether a hospital or the community) and requires all members of a health care team to hold each other accountable for the team’s performance; nurses must also be equipped with the communication, conflict resolution, and negotiating skills necessary to succeed in leadership and partnership roles. For example, one new quality and safety strategy requires checklists to be completed before certain procedures, such as inserting a catheter, are begun. Nurses typically are asked to enforce adherence to the checklist. If another nurse or a physician does not wash his/her hands or contaminates a sterile field, nurses must possess the basic leadership skills to remind their colleague of the protocol and stop the procedure, if necessary, until the checklist is followed. And again, nurses must help and mentor each other in their roles as expert clinicians and patient advocates. No one can build the capabilities of an exceptional and effective nurse like another exceptional and effective nurse.

Will Community Nurses Hear the Call?

Nurses working in the community have long understood that to be effective in contributing to improvements in the entire community’s health, they must assume the role of social change agent. Among other things, community and public health nurses must promote immunization, good nutrition, and physical activity; detect emergency health threats; and prevent and respond to outbreaks of communicable diseases. In addition, they need to be prepared to assume roles in dealing with public health emergencies, including disaster preparedness, response, and recovery. Recent declines in the numbers of community and public health nurses, however, have made the leadership imperative for these nurses much more challenging.

Community and public health nurses learn to expect the unexpected. For example, a school nurse alerted health authorities to the arrival of the H1N1 influenza virus in New York City in 2009 (RWJF, 2010c). Likewise, an increasing number of nurses are being trained in incident command as part of preparedness for natural disasters and possible terrorist attacks. This entails understanding the roles of and working with community, state, and federal officials to assure the health and safety of the public. For example, when the town of Chehalis, south of Seattle, experienced a 100-year flood in 2007, a public health nurse called the secretary of Washington State’s Department of Health, Mary Selecky, to ask how to “deal with and dispose of dead cows, an unforeseen challenge [for] a public health nurse. The nurse knew she needed [to provide] tetanus shots and portable toilets but had not anticipated other, less common, aspects of the emergency” (IOM, 2010).

The profile in  Box 5-5  illustrates how nurses lead efforts that provide critical services for communities. The profile also shows how nurses can also become leaders and social change agents in the broader community by serving on the boards of health-related institutions. The importance of this role is discussed in the next section.

BOX 5-5

Nurse Profile: Mary Ann Christopher.  Cultivating Neighborhood Nursing at the Visiting Nurse Association of Central Jersey  At the Visiting Nurse Association of Central Jersey (VNACJ), president and chief executive officer Mary Ann Christopher, MSN, RN,  (more…)

Will Chief Nursing Officers Hear the Call?

Although chief nursing officers (CNOs) typically are part of the hierarchical decision-making structure in that they have authority and responsibility for the nursing staff, they need to move up in the reporting structure of their organizations to increase their ability to contribute to key decisions. Not only is this not happening, however, but CNOs appear to be losing ground. A 2002 survey by the American Organization of Nurse Executives (AONE) showed that 55 percent of CNOs reported directly to their institution’s CEO, compared with 60 percent in 2000. More CNOs described a direct reporting relationship to the chief operating officer instead. Such changes in reporting structure can limit nurse leaders’ involvement in decision making about the most important product of hospitals—patient care. Additionally, the AONE survey showed that most CNOs (70 percent) have seen their responsibilities increase even as they have moved down in the reporting structure (Ballein Search Partners and AONE, 2003). CNOs face growing issues of contending not only with increased responsibilities, but also with budget pressures and difficulties with staffing, retention, and turnover levels during a nursing shortage (Jones et

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