Q&A: Nurse leaders on affecting outcomes through leadership, part II

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Alexandra Wilson Pecci, for HealthLeaders Media, March 5, 2013

Three nurse leaders from the Premier CNO Network, an organization made up of 235 CNOs from across the country that aims to promote networking, collaboration, advocacy, and peer-based learning share their views in an open-ended, roundtable discussion:

  • Kathleen D. Davis, RN, MBA, Senior Vice President and CNO of Presbyterian Healthcare Services in Albuquerque, NM;
  • Judy Watland, R.N., MSN, Senior Vice President and Chief Clinical Officer/Nurse Executive at O'Connor Hospital in San Jose, CA (part of Daughters of Charity Health System); and
  • Carolyn C. Scott, RN, M.Ed, MHA, vice president of performance improvement/quality for the Premier Healthcare Alliance

This is the second of two parts; read Part I here.

HLM: I seems like it would be really easy to get overwhelmed by all the changes that are coming with healthcare reform. Do you feel that's the case for nursing staff, and if so, how can leaders help alleviate that a little bit?

Davis: I think absolutely it can be overwhelming. I think leaders really have an obligation to communicate, to the extent that we can to bring clarity to the conversation, to help connect the dots and align.

I'm often a translator: why we have to do this, what does it mean to us, and what does it look like in our day-to-day work and how does it really link to other things that we're doing? So I think…simplifying the complexity in the discussion and in the work as much as you can is a critical skill for nurse leaders.

Watland: I would add to that. I think when people feel like they don't have any control it's more overwhelming and I think having ways that people can have a voice is really, really important. Even at the local level, or your employment level, having opportunities for nurses to have a voice in how things are shaped [is important].

I'll give you an example. We were at 12-hour shifts; I think most hospitals are. But we also had a pretty high-priced price tag on that which was a bonus that was being given to nurses for essentially working a 36-hour week and getting paid for 40. And that cost us a lot of money to do that.

And so essentially, we need to go back to eight-hour shifts because we can't afford to do this anymore. And it shaved off about between $5 and $6 million a year for us.

And we shared that with staff, we told them the why, we told them why it was so important. Not that everybody liked it, but people understood it, and got onboard and we worked together to make this change house-wide in 2011. They feel like they can trust you; they know the why.

Davis: Some of the changes we need to make are challenging. One for us is we don't have a high percentage of bachelor's-prepared nurses in our market and we have adopted the 80% BSN by 2010 principle, the strategic goal from the IOM report.

And now we're working to work through our career ladder and some of the other things we have in place to help move us in that direction. I would agree that the communication, input, [and] open dialogue, are critical to making changes, understanding the "why." Not just to irritate everyone, but to really help us grow and be viable in the future as a nursing community.

Scott: I would say to add on: This sounds really simple. But it's really such an important part of the process. When the bedside nurses understand the reasons for the requests, for changes in process or implementation of new processes, and understand how it aligns with what's in an IOM report or value-based purchasing or other healthcare reform legislation, they are so willing to get involved and help the organization meet the objectives.

And beyond that, there're some incredibly creative and innovative bedside nurses in each and every organization. I'm always amazed at the ideas and the strategies that they're even able to bring forward themselves; how to make something better. So the whole idea about communication and having a line of sight to why they're doing what they're being asked to do, I think is critical going forward.

HLM: What about nurse leaders themselves who are feeling overwhelmed?

Davis: Participation in networks and collaboratives, both at a state, regional, and national level, really do help in looking at benchmark performance; understanding how you compare to your peers does help bring clarity and focus to what you need to do.

And not unlike the challenges of the staff nurse, we have to practice what we're preaching so to speak, and really be able to clarify what are the priorities on our agenda and how to we move that forward.

So for me, that focus and discipline around the key things and really trying to find those high leverage points [is important]. Like what we were describing about staff involvement and ownership of the work helps you in many, many ways.

So how can you think through your tactics to say what will really help us move our agenda overall forward and what are the specific things we need to be doing?

Watland: The biggest challenge for me, and I think most people in healthcare is how do you continue to raise the bar and provide the best quality outcomes for the lowest price you can?

Because the resources for reimbursement… [are] going down, we have more people to provide care for, and quality is certainly absolutely one of the biggest challenges and goals that we all have.

To go back to how do you do that, you mentioned about confused and overwhelmed, and I think you do get overwhelmed if you start thinking about that in an isolated or siloed fashion.

But we can't do that. We have to be collaborative. We have to network. We have to work as a team. I think in the last few years, I have seen more collaboration and teamwork, and interdisciplinary kinds of work going on between physicians and nurses, and all of the ancillary services and nursing, coming together in an integrated manner to tackle these issues and together we need to be an extension for one another we need to make sure that we're providing the care that we need to provide.

It used to be more siloed than it is now. And I think our new and especially our younger healthcare professionals are really looking to do this as a more collaborative model and really respecting each other as they do it. In leadership, in senior leadership, we have an obligation to foster that and to cultivate that culture and making sure that we're working in collaboration to do this. This is not nursing's challenge alone. Nursing has a huge [role], and we provide the majority of care in a hospital setting. We have a huge obligation to have a voice, but we also have a huge obligation to have a collective voice with the other disciplines, and I think that's one of the things that I really try to foster here.

Because you can get so much more done if you're working together.

Davis: I would totally agree. A more tangible way that we're doing that [is] we're in the process of preparing to change our electronic health record from one vendor to another, and our new opportunity with the new vendor is to really bring together the inter-professional team in a way where we're really looking at the care process.

How are we doing the work for our patients together? How are we eliminating unnecessary duplication? How are we sharing information better? For us, that's been a very tangible way and coming together as a clinical governance overseeing the redesign of our EHR in a really tangible way that will directly impact what we do every day.

I couldn't agree more that this is a team sport, and I think as Judy said, these are not nursing's issues alone. It's a requirement that we not only model, but really engender the high levels of collaboration that are required to move us forward.

HLM: Let's move onto nurse leadership trends. What are you seeing?

Watland: I think there's a trend that we're going to be seeing again, that's quite concerning to me, is that we're going to be starting to see a nurse shortage again.

The pendulum swung from nurse shortage—at least here, where I am, in California—to having more than adequate numbers of nurses available to the point that new nurses coming out of school can't get jobs. And that trend as I'm reading about the aging population in nursing, that's going to shift.

Also what's going to be shifting is the nurse leadership positions that are going to be vacated because of this aging population in nursing. And I think we need to take that very seriously: How do we continue to support the pipeline for new nurses as they are coming into the profession? [Also,] making sure that we're helping people to get jobs and having standardized transition methods [so] people are ready to take clinical positions and to function at the bedside when they're getting out of school.

I think we need to be working with schools to do that. And I also think we need to be doing really good succession planning to help foster and help people to go into these nurse leadership positions. It's a difficult job, especially middle management; I think that's the most difficult job there is in the hospital, and to help people, number one, be attracted to that role and how do we do that? And also how to be help them be successful in that role?

Davis: Faculty shortage is a critical issue. In fact, I think that the community leadership around preparing for innovation, not just within your institution, but looking at innovation in nursing education. Our community just received a…grant from the Robert Wood Johnson Foundation on an innovative program to help nurses [move] more quickly from associate degree right into bachelor's degree programs.

How do you as a nurse leader interact with your state issues, your local community, issues in the school and provide support and leadership around the infrastructure that we need to be ready for these types of changes?

I think that being able to be agile and handle multiple concepts, work with diverse groups on particular challenges, and to be able to use some of the principles of innovation [is important].

How can we step over some issues and create some new solutions, whether it's internally within your care model or in your community? Also, I see the requirement to have a more disciplined practice in terms of understanding what required work is, helping our profession and others to stop doing things that don't add value to the patient care experience.

Using, as Judy was saying, evidence-based practice to really analyze and understand whether this something we need to be doing, can we stop doing this. Do we really need to focus on some different things in terms of providing services to patients?

HLM: What other important take-aways do you have to offer?

Watland: Nurses get in leadership roles, at least traditionally, when they're good clinically. So you have to have this clinical expertise, and then you rise to the awareness of someone that maybe you could be a leader. But today's leaders have to be so much more than that.

I really think with healthcare reform we have to have new skill sets and we have to be making sure that we have not only the clinical awareness...and make sure that we're providing quality care, but we have to have business knowledge, we have to understand financial principles and how to do productivity management.

We have to know how to sit at the board…and speak for nursing and have nursing have a voice, to get the things that we need to get to help provide better patient care. And I think we really need to be innovative thinkers and inventive thinkers. Now that healthcare reform is coming in it's a whole new world; we have to think and do things differently.

We have to be risk-takers; we have to support each other. I think nursing has to be very collaborative and cohesive in that we share what's working and what's not working, and that we're not competitive about it. And really take on some new challenges and deal with them in different ways than we have in the past because healthcare reform is going to demand that of us.

Davis: I would add to that...we're an integrated delivery system. Because of that, I really have the opportunity to look at and to work within our leadership organization with nursing colleagues about what does that mean for a patient when you're in a total prepaid environment. You're the insurer as well as the delivery system for care—and how does that change how we think about our accountability for managing the patient across the continuum?

[There are] some of the innovations in our care model...we have a program that we call Hospital at Home where we bring higher acuity patients into the home and provide more intense nursing care, higher acuity nursing care, and physician visits for patients who would ordinarily be in the hospital setting.

And for us, we can do that at less cost and with great outcomes for the patient. But really [we're] looking across our whole system, not just as a deliverer of services, but also as the financer of the care. And I think that is really the future and the sooner we can think more systematically, and prepare for that we'll be better positioned to be prepared for change.

Watland: We can also take a leadership role in how do we expand the scope of, well maximize is the better way to put it...

Davis: Work to the highest level of the licensure...

Watland: Right, the licensure and the level of education, and especially advance practice nurses and nurse practitioners. In fact I was in a meeting this morning, a medical staff meeting...and I was really pleased to hear the physicians comment about being able to use [APRNs] to their fullest potential in the acute care setting. And [they were] really supporting that, and I think we need to be really promoting that and helping that to happen.

[Not only] advance practice nurses, but also our general trained nurses: How do we maximize that resource? And I don't mean overwork, but [let's] maximize their ability to function to the highest level of their licensure.

Source: HealthLeaders Media