Nurses as leaders: At all levels, in all settings

by Linda Gobis

Nursing leadership is vitally important to our profession, now more than ever. I do not mean traditional leadership with its hierarchy of formal positions, but rather, all nurses everywhere engaged in grassroots leadership. Why this change? Why now?

In 2010, the Institute of Medicine (IOM) published “The Future of Nursing Leading Change Advancing Health” report.[i]  The authors concluded that the nursing profession was central to redesigning the health care system. The Future of Nursing report had four key messages to guide nurses. They were as follows:

• Key Message #1: Nurses should practice to the full extent of their education and training
• Key Message #2: Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression
• Key Message #3: Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States
• Key Message #4: Effective workforce planning and policy making require better data collection and an improved information infrastructure[ii]

Key message #3 addresses nursing leadership. Do you see yourself as a nursing leader? Really think about that question for a minute. Do you really see yourself as a leader?  The answer should be yes!

Nurses as Leaders

The Robert Wood Johnson Foundation (RWJF) in partnership with AARP funded implementation of the IOM report nationwide. This was done through the Center to Champion Nursing in America which was comprised of fifty-one state coalitions, including the Wisconsin Center for Nursing (WCN).

Key message #3 explains that “nursing leadership is needed at every level and across settings.”[iii]  What does that type of leadership look like?  Key Message #3 gives the following examples:

• Improve front line work processes
• Create integrated practice models
• Develop organizational policies which allow nurses to function at their fullest capacity in collaboration with others
• Change curriculums to educate students to meet community and patient needs
• Translate and apply research findings into practice and models of care
• Serve on boards where critical patient care decisions are made

Those ideas do not sound too hard; they are also very general. Recommendation #7 gives more specific leadership suggestions for specific groups of nurses, including:

• Nurses, nursing education programs, and nursing associations should prepare nurses to assume leadership positions across all levels
  • Nurses—be responsible for personal and professional growth through lifelong learning and pursuing opportunities to develop and exercise leadership skills
  • Nursing education programs—integrate leadership theory and business practices into curriculum and clinical experiences
  • Nursing associations—provide leadership development, mentoring programs, and leadership opportunities for all members
• Public, Private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses
  • Public, private, and governmental healthcare decision-makers—include nursing representation on boards, executive management teams, and other key leadership positions across all levels[iv]

Why did the IOM make these recommendations? One reason is public perceptions of nurses.  Nurses comprise the largest segment of the health care workforce. According to the World Health Organization there are over 19 million nurses worldwide[v].  Therefore, you can make a significant impact if you use the voice you already have. A 2015 Gallop poll “Honesty/Ethics in Professions”[vi] showed once again that the public believes nurses are the most honest and ethical profession.  Not only are we the most ethical, but nurses are 17 percentage points above all other professions.  A 2010 Gallop poll of 1500 opinion leaders “Nursing Leadership from Bedside to Boardroom”[vii] found the top barriers to increased nursing influence and leadership are perceptions that nurses are not decision-makers or revenue generators (i.e. compared to physicians) and focus on preventative rather than acute care.  Finally, policymakers have historically perceived nurses as functional doers rather than thoughtful strategists.[viii]

A second reason for the IOM recommendations is nurses’ perceptions about themselves.  Many bedside nurses do not believe they are leaders because they do not hold positions of power, despite having long-term impact on their patients.  Some nursing faculty perceive their influence in terms of semesters or the number of students sitting in a classroom, even though faculty teach the future workforce of the profession.

Lastly, nurses remain divided over key issues and cultural challenges (e.g. lateral bullying).  Policymakers and others would like to assist the profession, but find mixed messages from nurses confusing. Building consensus among nurses and then speaking with one voice would significantly improve the likelihood of assistance from others.

Despite these perceptions, what progress have we made in the last six years implementing the Future of Nursing report?  A 2015 follow-up report “Assessing Progress on the IOM Future of Nursing Report”[ix] showed that the greatest progress has been made in workforce data collection.  Work is still needed in areas like collaborating and leading in health care delivery and redesign, such as: 1) tracking programs and courses in leadership entrepreneurship and management to assess progress, and 2) focusing on nurses in leadership positions other than board positions.

Moving Forward

The Robert Wood Johnson Foundation (RWJF) funding of the Campaign For Action will end in January 2017.  The 51 state coalitions must continue their work independently after that. The Wisconsin Center for Nursing has proposed forming a Quad Council in Wisconsin. Proposed membership would include the Administrators of Nursing Education of Wisconsin (ANEW), Wisconsin Center for Nursing (WCN), Wisconsin Nurses Association (WNA) and the Wisconsin Organization of Nurse Executives (WONE).  The Quad Council would carry on the work of the Wisconsin Action Coalition that was previously done by the Wisconsin Center for Nursing.  Each member would provide leadership, and develop strategical goals and priorities for their portion of the state coalition work. For example, WNA would be responsible for legislative and political advocacy for members’ goals and priorities as needed.

To move forward effectively, nursing needs to view itself through a new lens and create a new paradigm of nursing leadership. In the new vision, every nurse would need to see her/himself as a leader. In other words, leadership would be an inherent aspect of being a nurse reflected in words, behavior, and actions important to nurses as professionals.

Andrus and Shanahen[x] recently proposed core characteristics of a holistic leader, which reflect the type of transformational leadership that is needed. The characteristics embody an emerging concept of nursing leadership as a starting point.[xi]  The seven characteristics are as follows:

• Visionary—open to learning other points of view, sees “big picture,” “out of box” thinker
• Inspirational presence—inspires others to be best self, embodies personal integrity
• Role model—sets standards of excellence, positive example for others to follow
• Mentor—mutually beneficial, shared process where partners learn and grow from each other
• Champion for clinical excellence—supports education & learning at every level, invests in ongoing professional development & clinical competence
• Courageous advocate—creates a culture & work environment that fosters caring for nurses, enhanced patient experiences, & builds community partnerships
• Cultural transformational agent—actualizes plans to transform organizational culture, supports nurse well-being, creates opportunities for nurse empowerment, & develops infra-structure for collaborative practice[xii]

This is a tall order for all nurses whether you have 1 year or 40 years of experience. Ask yourself, how can I contribute?  How do I live up to these characteristics and expectations?  The IOM Future of Nursing Report provides a roadmap.[xiii]  It includes:

• Front Line Nurses developing:
  • New models of care to improve quality, efficiency, & safety
  • New workplace cultures that support leadership at the point of care
  • Communication, conflict resolution, & negotiating skills to succeed in leadership
• Community Nurses serving as social change agents to:
  • Promote immunization, good nutrition, & physical activity
  • Detect emergency health threats
  • Prevent and respond to outbreaks of communicable diseases
  • Assume roles in dealing with public health emergencies, including disaster preparedness, response, and recovery
• Chief Nursing Officers increasing their ability to contribute to key decisions by moving up the reporting structure
• Nurse Researchers developing:
  • New models of quality care that are evidence based, patient centered, affordable, and accessible to diverse populations
  • Translate research findings into nursing practice
  • Use research findings to develop evidence-based state and federal health care policy agendas that increase quality and access while decreasing costs and health care disparities
• Nursing Organizations reducing fragmentation in nursing organization leadership[xiv]

Answering the Call to Lead[xv]

You may be wondering if resources are available to assist you in becoming a grassroots leader or just learning more about leadership in general. Yes, there are leadership programs, mentorship opportunities, and policy making or political engagement resources as discussed in the Future of Nursing Report.[xvi]

Wisconsin has several leadership programs for nurses including:

• Wisconsin Organization of Nurse Executives (WONE) biannual Nursing Leadership Academy http://wisconsincenterfornursing.org/documents/Leadership%20Collaborative%20Minutes/NurseLeadershipAcademy%20Brochure%20FINAL%20Jan%202015.pdf
• UW Hospitals & UW School of Nursing Clinical Leadership Institute http://wisconsincenterfornursing.org/documents/Leadership%20Collaborative%20Minutes/2014%20WI%20Nsg%20Leadership%20Development%20Programs%20Jan%202015%20Update.pdf
• Rural Wisconsin Health Cooperative focus on leadership in general
• Wisconsin Center for Nurses (WCN) Leadership Toolkit https://www.wcnursing.org/wnac-apin/leadership-toolkit/
  • Articles, books and other references on aspects of nursing leadership
• Magnet Recognition Programs in Wisconsin hospitals

Nursing mentorship opportunities are available at both the national and state levels.  National associations that provide mentorship and leadership guidance, as well as opportunities to members to share expertise and best practices, include: 1) the American Association of Colleges of Nursing (AACN) nursing education experts, 2) the National League of Nursing (NLN) Academy of Nurse Educators, and 3) the American Academy of Nursing (AAN) Edge Runners.

The Wisconsin Nurses Association (WNA) also has mentorship resources. The WNA Mentorship Program holds monthly calls for groups to discuss nursing topics and/or experiences in the work place, and give advice on problems.  The 2016 Fall Learning Symposium offered several workshops and conferences, such as “Surviving Your First Year”, “Engaging in the Political Process Through Grassroots Advocacy” and “Clinical and Interprofessional Considerations for Patient-Centered Team-Based Care.”  Finally, the WNA Future Nursing Leader Award program recognizes five undergraduate students every semester who are exemplary leaders and embody the ethics and values of the nursing profession.  The award includes participation in the WNA Mentorship Program.

Do you view the healthcare policymaking process and political engagement as an obligation to shape policy, or rather, something that happens over which you have no control?[xvii]  Every nurse should commit to being personally engaged in policy decisions at the national, state, local, institutional or practice setting.  Novice nurses may want to begin by pursuing practice partnerships and organizational policymaking.  For example, improving policies on quality, access and health care value.  Alternatively, working to improve patient care to be truly patient centered.  If you prefer politics, begin with voting in local and state elections or sharing research findings and best practices with state officials or elected representatives regarding proposed/revised legislation.

WNA is involved in policymaking and has opportunities for interested members.  The Public Policy Council reviews proposed legislation which impacts nursing and recommends organizational positions to the WNA Board of Directors.  The work of the Public Policy Council and other WNA policymaking activities is reflected in the “WNA Working For You” document available on the WNA website. WNA just published its Legislative and Regulatory Agenda for the 2017 to 2019 Biennium.  Nurses Day at the Capitol is an annual event for members to learn about political and legislative hot topics and make in-person visits to legislators at the Capital.

Will you pick up the banner and be a nursing leader? If you already exemplify nursing leadership, will you push yourself to expand your leadership area or improve your skills?  Where ever you are on the continuum, will you join me in grassroots nursing leadership to transform and redesign health care in Wisconsin?  As nurses, we all must do our part!

[i] National Academies of Sciences, Engineering and Medicine. (2010). The future of nursing: Leading change advancing health. Washington, D.C.: Institute of Medicine of the National Academies Press.

[ii] National Academies of Sciences, Engineering and Medicine. (2010). The future of nursing: Leading change advancing health (pp. 58-63). Washington, D.C.: Institute of Medicine of the National Academies Press.

[iii] National Academies of Sciences, Engineering and Medicine. (2010). The future of nursing: Leading change advancing health (pp. 32 & 221). Washington, D.C.: Institute of Medicine of the National Academies Press.

[iv] National Academies of Sciences, Engineering and Medicine. (2010). The future of nursing: Leading change advancing health (pp. 282-283). Washington, D.C.: Institute of Medicine of the National Academies Press.

[v]Rosa, W. (2016). Preface. In Rosa, W. (Ed.), Nurses as leaders: Evolutionary visions of leadership (p. xxiv). New York, NY: Springer Publishing Company

[vi] Gallop. (2015). Honesty/Ethics in Professions poll. Retrieved from http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx

[vii] Gallop. (2010). Nursing Leadership from Bedside to Boardroom. Retrieved from http://www.rwjf.org/en/library/research/2010/01/nursing-leadership-from-bedside-to-boardroom.html

[viii] Porter-O’Grady, T. (2011). Future of nursing special: Leadership at all levels. Nursing Management, 42:5, 32-37. Retrieved from http://www.nursingcenter.com/journalarticle?Article_ID=1163290

[ix] National Academies of Sciences, Engineering and Medicine. (2015). Assessing progress on the IOM report the future of nursing. Washington, D.C.: Institute of Medicine of the National Academies Press.

[x] Andrus, V.L. & Shanahan, M. (2016). Holistic leadership. In B.M. Dossey & L. Keegan (Eds.) Holistic nursing: A handbook for practice (7^th ed.). Burlington, MA: Jones & Bartlett.

[xi] Rosa, W. (2016). Introduction. Nurse as leader: A journey of privilege. In Rosa, W. (Ed.), Nurses as leaders: Evolutionary visions of leadership (p. 3). New York, NY: Springer Publishing Company

[xii] Andrus, V.L. & Shanahan, M. (2016). Holistic leadership. In B.M. Dossey & L. Keegan (Eds.) Holistic nursing: A handbook for practice (7^th ed., pp. 591-607). Burlington, MA: Jones & Bartlett.

[xiii] National Academies of Sciences, Engineering and Medicine. (2010). The future of nursing: Leading change advancing health. (pp. 234-241). Washington, D.C.: Institute of Medicine of the National Academies Press.

[xiv]National Academies of Sciences, Engineering and Medicine. (2010). The future of nursing: Leading change advancing health. (pp. 234-241). Washington, D.C.: Institute of Medicine of the National Academies Press.

[xv] National Academies of Sciences, Engineering and Medicine. (2010). The future of nursing: Leading change advancing health (pp. 241-250). Washington, D.C.: Institute of Medicine of the National Academies Press.

[xvi] National Academies of Sciences, Engineering and Medicine. (2010). The future of nursing: Leading change advancing health (pp. 241-250). Washington, D.C.: Institute of Medicine of the National Academies Press.

[xvii] National Academies of Sciences, Engineering and Medicine. (2010). The future of nursing: Leading change advancing health (pp. 222). Washington, D.C.: Institute of Medicine of the National Academies Press.