LEADERSHIP AND CHANGE AGENT
¢ It is an exciting time for nursing in the United States however, there are a number of key challenges facing CNSs as nurse leaders.
In health care, the focus is no longer just on the process of how care is delivered, but on the outcomes of that care. More attention is being given to documenting that the care is provided according to specific standards associated with better outcomes. Many of the standards are directly related to the care given by nurses, including some indicators that are specifically sensitive to nurse intervention. There is also a new focus on federal reporting of patient satisfaction with the services provide. Producing quality outcomes, high patient satisfaction and effective measurements of both are now a central theme for the entire hospital administrative team. For the CNS, however, it represents explicit accountability for managing and leading the staff responsible for providing the patient care. The ability to assure nursing effectiveness will likely be achieved by redesigning the manner in which nurses work and deliver care. Safety and quality issues are directly linked to financial pressure. Reimbursement for hospital services is being whittled away as financial accountability for services receives greater scrutiny from the federal government and private insurers. Close on the heels of the financial challenge is the ever present workforce shortage. Another troublesome challenge is the absence of an adequate pipeline for nursing leaders. Current nurse leaders in the U.S. are in their 50s and anticipated retirements may reduce leadership numbers to critical levels. There is an urgent need to develop new leaders at all levels. Middle management vacancies in roles such as the CNS and nurse manager are extremely difficult to fill. (Thompson, P.A. (2008). Key challenges facing American nurse leaders. Journal of Nursing Management, 16, 912).
Leadership is a hallmark of CNS practice in all three spheres of influence. The essence of leadership is fundamentally the capacity to influence. Influence is the power of producing an effect without apparent exertion of force or direct exercise of command (Merriam-Webster Online Dictionary, 2008). Influence and, therefore, leadership is not about having postion authority; it is the ability to get others to be motivated to work toward accomplishing a vision. The importance of influence as the major avenue through which CNSs positively impact both patient outcomes and cost-effectiveness is reflected in the adoption of spheres of influence as the framework for the Natinal Association of Clnical Nurse Specialists (NACNS) Statement on Clinical Nurse Specialist Practice and Education (2004). (Lyon, BL (2010), Transformational leadership as the clinical nurse specialists capacity to influence, pp149. In Clinical Nurse Specialist Practice, Springer Publishing).
Because the CNS is often charged with directly or indirectly monitoring quality of care, this advanced practice nurse is uniquely positioned to effect change throughout and across the health care continuum. Richardson (2010) identifies a number of characteristics of successful change agents:
ability to combine unrelated ideas, ability to energize others, skill in human relations, integrative thinking (big-picture focus and detail oriented), flexibility to modify ideas, persistence to resist nonproductive tampering; confidence, realistic thinking regarding timelines, trustworthiness, history of previous successes, ability to articulate a vision, ability to handle resistance (p81).
CNS Core Competencies (NACNS, 2010)
Systems Leadership Competency: The ability to manage change and empower others to influence clinical practice and political processes both within and across systems.
C. 1 Facilitates the provision of clinically competent care by staff/team through education, role modeling, teambuilding, and quality monitoring.
C.2 Performs system level assessments to identify variables that influence nursing practice and outcomes, including but not limited to:
C.2.a. Population variables (age distribution, health status, income distribution, culture)
C.2.b. Environment (schools, community support services, housing availability, employment opportunities)
C.2.c. System of health care delivery
C.2.d. Regulatory requirements
C.2.e. Internal and external political influences/stability
C.2.f. Health care financing
C.2.g. Recurring practices that enhance or compromise patient or system outcomes.
C.3 Determines nursing practice and system interventions that will promote patient, family and community safety.
C.4 Uses effective strategies for changing clinician and team behavior to encourage adoption of evidence-based practices and innovations in care delivery.
C.5 Provides leadership in maintaining a supportive and healthy work environment.
C.6 Provides leadership in promoting interdisciplinary collaboration to implement outcome-focused patient care programs meeting the clinical needs of patients, families, populations and communities.
C.7 Develops age-specific clinical standards, policies and procedures.
C.8 Uses leadership, team building, negotiation, and conflict resolution skills to build partnerships within and across systems, including communities.
C.9 Coordinates the care of patients with use of system and community resources to assure successful health/illness/wellness transitions, enhance delivery of care, and achieve optimal patient outcomes.
C.10 Considers fiscal and budgetary implications in decision making regarding practice and system modifications.
C.10.a. Evaluates use of products and services for appropriateness and cost/benefit in meeting care needs
C.10.b. Conducts cost/benefit analysis of new clinical technologies
C.10.c. Evaluates impact of introduction or withdrawal of products, services, and technologies
C.11 Leads system change to improve health outcomes through evidence based practice:
C.11.a. Specifies expected clinical and system level outcomes.
C.11.b.Designs programs to improve clinical and system level processes and outcomes.
C.11.c.Facilitates the adoption of practice change
C.12 Evaluates impact of CNS and other nursing practice on systems of care using nurse-sensitive outcomes
C.13 Disseminates outcomes of system-level change internally and externally
Hamric, A.B., Spross, J.A., & Hanson, C.M. (2008). Clinical and professional leadership, 249-282. Textbook
Huston, C. (2008). Preparing nurse leaders for 2020. Journal of Nursing Management, 16, 905-911. Huston 2008.pdf
Shirey, M.R. (2008). Influencers among us. A practical approach for leading change. Clinical Nurse Specialist. 22(2). 63-65. Shirey-Influencers among us 2008.pdf
Shirey, M.R. (2007). Leadership and organizational strategies to increase innovative thinking. Clinical Nurse Specialist. 21(4), 191-194. Shirey-Leadership & Org Strat 2007.pdf
Shirey, M.R. (2007). Moral intelligence for the leader and entrepreneur. Clinical Nurse Specialist, 21(2), 71-73. Shirey-Moral Intelligence 2007.pdf
Spreir, Fontaine, & Malloy (June 2006).Leadership run amok: The disruptive potential of overachievers. Harvard Business Review, 72-82. Spreier-Leadership-2006.pdf
Keele, R. (2012. Implementing evidence-based nursing practice: An overview. In Nursing Research and Evidence -Based Practice: Ten steps to success. Hones & Bartlett Learning, LLC. 80586_CH05_Keele.pdf
Goleman, D. & Boyatzis, R. (2008). Social intelligence and the biology of leadership. Harvard Business Review, 86(9), 74-81. Biology of leadership.
Discuss how CNS leadership and change agent roles will play out in your clinical practicum project. Relate discussion to the literature cited in your reading list. Be sure to briefly explain purpose of your project in 2 sentences.
LEADERSHIP AND CHANGE AGENT