There is growing evidence in the nursing literature regarding the positive impact of healthy work environments on staff satisfaction, retention, improved patient outcomes, and organizational performance. The establishment of a healthy work environment requires strong nursing leadership at all levels of the organization, but especially at the point of care or unit level where most front line staff work and patient care is delivered.
Growing future nurse leaders is a long term quest. It can be challenging for today’s leaders to predict what knowledge, skills, and abilities will be needed to lead in the future. This article presents a review of the literature regarding the importance of healthy work environments in healthcare organizations and the significant role of nurse leaders in building and sustaining these healthy environments. It also discusses the development of leadership skills by presenting the Nurse Manager Leadership Collaborative Learning Domain Framework, a widely used competency model for nursing leadership development that can serve as a useful resource in the development of leaders at the unit level.
Key words: business of caring, Clinical Nurse Leaders, communication, conflict management, development, emerging nurse leaders, healthy work environments, leadership, Nurse Manager Leadership Collaborative Learning Domain Framework, NMLC, nursing
There is growing evidence in the nursing literature about the positive impact of a healthy work environment on staff satisfaction, retention, improved patient outcomes, and organizational performance (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Shamian & El-Jardali, 2007). Many organizations, including the American Association of Critical Care Nurses (2005), the American Nurses Credentialing Center (2008), the Institute of Medicine (2004), the International Council of Nurses (2007), and the American Association of Colleges of Nursing (2002), have outlined criteria that characterize a healthy work environment. The Nursing Organizations Alliance, a coalition of major nursing organizations throughout the United States (US), issued a joint position statement that identified the following nine key elements that support the development of healthful practice/work environments:
- A collaborative practice culture
- A communication rich culture
- A culture of accountability
- The presence of adequate numbers of qualified nurses
- The presence of expert, competent, credible, visible leadership
- Shared decision making at all levels
- The encouragement of professional practice & continued growth/development
- Recognition of the value of nursing’s contribution
- Recognition by nurses for the their meaningful contributions to practice
(Nursing Organizations Alliance, 2004)
Although much work has been done to identify what needs to happen in practice environments to maximize the health and well being of nurses, the achievement of these key elements has proved challenging for many organizations in today’s turbulent healthcare environment (Laschinger, 2007; Ulrich et al, 2009). The establishment of a healthy work environment requires strong nursing leadership at all levels of the organization, but especially at the point of care or unit level where most front line staff work and where patient care is delivered. With the changes that have occurred in the nurse manager role over the past two decades, which include multiple-unit management and increased responsibility for budget, staffing, and regulatory compliance (Sherman, Bishop, Eggenberger, & Karden, 2007; Shirey & Fisher, 2008), leadership at the point of care is now often provided by nurses in roles such charge nurse, unit facilitator, or clinical nurse leader.
If a healthy work environment is to be achieved at the unit level, current and future nurses in these unit-level roles and the nurse manager role will need development and mentoring to develop the leadership skills needed to support the development of healthy work places. In this article the authors will present a review of the literature addressing the importance of healthy work environments in healthcare organizations and the significant role of nurse leaders in building and sustaining these healthy environments. They will also discusses the development of leadership skills, presenting a widely used competency model for nursing leadership development, namely, the Nurse Manager Leadership Collaborative Learning Domain Framework, a useful resource in the development of unit leaders.
Review of the Literature: Building and Sustaining Healthy Work Environments
Leaders can help create a deeply satisfying organizational culture at the unit level by engaging staff in the development of shared values in their work. A healthy work environment cannot occur without nurse leaders who support its importance, authentically live it, and engage others in its achievement (AACN, 2005). Kramer and Schmalenberg (2008) observed that only staff nurses can confirm whether initiatives planned and designed to improve the health of a work environment are successful. Accessible nursing leaders play a key role in helping to give nurses a voice in the improvement of patient care environments (AACN, 2005). This leadership must be available 24/7. Leaders can help create a deeply satisfying organizational culture at the unit level by engaging staff in the development of shared values in their work. This entails a paradigm shift from a more traditional command-and-control style of staff supervision toward a transformational style of leadership in which leaders enhance the motivation, morale, and performance of their follower groups. The positive relationship between this type of transformational leadership and satisfaction of staff is supported by research (Faila & Stichler, 2008).
A failure to take steps to build cultures of engagement can lead staff to feel that they are not supported in their work. It may also result in staff making a decision to leave an organization. There is evidence in the literature that work environments are evaluated as being more healthy and staff retention is better when staff feel supported by their nurse manager (Kramer et al. 2007; Shirey, 2006). The American Association of Critical Care Nurses has worked collaboratively with the Gannett Healthcare Group and the Bernard Hodes group to conduct national surveys of critical care nurses to assess the progress and impact of their healthy work environment standards. Their findings from the 2006 and 2008 studies indicate that issues still remain in the work environment that can impede the quality of care, safety of patients, and RN job satisfaction. They cite a need for improved leadership to improve staff perceptions of leadership support and reduce turnover in critical care units (Ulrich et al. 2009).
A failure to take steps to build cultures of engagement can lead staff to feel that they are not supported in their work. Some organizations are taking significant steps to improve their work environments. Achievement of Magnet recognition through the American Nurses Credentialing Center (ANCC) Magnet Recognition Program® is considered in nursing to be the gold standard for hospitals seeking to build professional practice environments that are healthy and support the work of nurses. Magnet practice environments include five major components: transformational leadership; structural empowerment; exemplary professional nursing practice; new knowledge, innovations and improvements; and empirical quality outcomes (ANCC, 2008). These components or forces of magnetism have evolved since the early 1980s when the American Academy of Nurses (AAN) first commissioned a study to determine why, during a competitive time, certain hospitals did not experience a shortage of nurses. What was found were elements of healthy practice environments, environments where nurses were respected, valued, and had a “voice.” Forty-one of the hospitals studied were identified as Magnet organizations. Currently there are 340 ANCC-designated Magnet hospitals and another 199 hospitals in the application process (C. Hagstrom, personal communication. July 31, 2009).
Research with Magnet-designated hospitals continues to identify important aspects of healthy practice environments (Drenkard, 2009). Findings have provided evidence supporting that Magnet hospitals have increased patient and nurse satisfaction, improved recruitment and retention of nurses, and improved patient outcomes (Aiken et.al., 2000/2009; Stone & Gershan, 2009; Stone et.al., 2006/2009). The effects of the Magnet professional practice environments on patient care were reported in several studies. Improvements in morbidity and mortality rates, failure-to-rescue rates, and patient safety were noted (Aiken et.al., 2008/2009; Armstrong et.al., 2009, Ulrich et.al., 2007/2009). Ulrich’s study further concluded that even hospitals “in the process” of Magnet designation showed significant improvements in their nurse and patient outcomes because of the improved practice environments. The evidence clearly supports that Magnet practice environments are exemplars of healthy care environments that support professional nurse practice and quality patient care.
Another innovative leadership approach to promote healthy work environments at the unit level has been the utilization of the Clinical Nurse LeaderSM (CNL)® role. The CNL role is new to nursing. This role evolved in 2004 as an outcome of meetings that the American Association of Colleges of Nursing had held with stakeholders to discuss what changes were needed in nursing education for the future. Participating nursing leaders were urged to think completely out of the box as they looked at the issues and challenges of today’s healthcare delivery system. Their discussions led to the design of the CNL role and the initiation of the CNL pilot project (American Association of Colleges of Nursing, 2007). In her role as a CNL project consultant, Tornabeni (2006) noted that the context of how nurses practice has changed and the work of nursing and patient care environments needed to be realigned to reflect this.
Interest in the CNL role continues to build nationwide as nurse leaders face a healthcare environment where retention of the workforce is critical, reimbursement is based on indicators sensitive to nursing care, and patient safety is a growing concern. CNLs work collaboratively with their nurse managers. They help to reduce the contentious relationships and communication problems that AACN (2005) described in the healthy work environment standards document. These problems can occur between nurses and administrators when nurse managers have responsibilities and spans of control that make it difficult both to track and monitor patient outcomes as well as to assume responsibilities for coaching the staff. Coaching and mentoring of inexperienced staff is an important component of the CNL role. CNLs are expected to guide the clinical team by encouraging professional development, providing continuing education, and promoting clinical excellence and collegiality. CNLs are in a unique position to promote a healthy work environment at the unit level because their practice is at the point of care. They also have a strong academic preparation designed to build key leadership skills to support staff. Although the jury is still out on the long-term success of the CNL role on a national level, there is great optimism that this innovative nursing role holds much promise to promote healthier work environments at the unit level (Harris & Ott, 2008; Sherman & Clark, 2008; Stanley et al., 2008).
Unfortunately, many organizations are not investing resources in the development of both current and future nurse leaders, helping them to build the skills needed to promote healthy work environments (Sherman, Bishop, Eggenberger, & Karden, 2007). O’Neil, Morjikian, Cherner, Hirschkorn, & West (2008) found in their research that the greatest single barrier to nurses accessing leadership and professional development opportunities was the inability to get time off the unit to invest in the acquisition of new skills. In many organizations, very little attention is being paid to succession planning and the development of emerging nurse leaders at the point of care (Stichler, 2008).
Development of Leadership Skills
The development of leadership skills should be viewed as a journey. The development of leadership skills should be viewed as a journey. Many current leaders in healthcare today were selected for their roles because of their clinical and technical proficiency (Sherman, Bishop, Eggenberger, & Karden, 2007). The attributes and behaviors that leaders need to support the development of healthy work environments are often identified as the “soft skills” (Shirey, 2006). Soft skills are often difficult for leaders to develop. Jack Welch (2001), the former Chairman of General Electric, noted that he spent a great deal of resources on leadership development because “Giving people self-confidence is by far the most important thing that I can do. Because then they will act” (p. 26). Self assessment instruments and 360 degree evaluations can be very powerful tools to help current and emerging nurse leaders assess their current strengths and weaknesses in the different dimensions of leadership. Examples of assessment tools that are frequently used in leadership training include the Center for Creative Leadership’s 360 Degree Evaluation, the Myers-Brigg Type Indicator, Kouzes and Posner’s Leadership Practices Inventory, and the Thomas-Kilman Conflict Mode Instrument.
It is challenging for today’s leaders to predict what knowledge, skills, and abilities will be needed to lead in the future healthcare delivery system. A competency model that is now widely used for nursing leadership development at the unit level is the Nurse Manager Leadership Collaborative (NMLC) Learning Domain Framework (NMLC, 2006) presented in the Figure. Nurse-manager leadership is necessary to support the development of healthy work environments. To address this need for leadership development, the American Organization of Nurse Executives, the Association of periOperative Registered Nurses, and the American Association of Critical Care Nurses worked collaboratively to develop a model that would identify competency domains needed by current and future nurse leaders. In addition to the model, a Nurse Manager Inventory (NMLC,2004) was developed which outlines key skills needed by nurse managers in each competency domain area. The inventory can be used to develop charge nurses, unit facilitators, and emerging leaders. It is available at no cost and allows nurses to use Benner’s novice-to-expert scale to rate themselves on a variety of key leadership skills (Shirey, 2007). The three domains in the framework (see Figure below) also provide a useful structure to plan leadership development activities targeted to growing current and future nurse leaders at the unit level.
Domain One - The Leader Within: Creating the Leader in Yourself
A key domain in the NMLC (2006) Leadership Domain framework is the Leader Within. Leadership skills begin with understanding one’s self. Personal mastery is a critical component for leadership success. Outstanding leaders demonstrate self-confidence and are able to trust and empower others. They know how their communication and actions impact others and are sensitive to watching the cues in an environment when things are not going well. These cues might include, for example, staff silence when a leader has asked for input. They develop an awareness of the importance of emotional intelligence in leadership. This authenticity in nursing leadership is often described as the glue needed to hold together a healthy work environment. Shirey (2006) has proposed that becoming an authentic leader requires self-discovery, self improvement, reflection, and renewal.
Leadership skills begin with understanding one’s self. Ideally, this development would take place as part of an emerging leaders program that could include self-assessment tools, presentations, group discussions, reading assignments, journal reflections, experiential activities, and application exercises. Strong coaching from an experienced and respected nursing leader who helps an emerging leader with self-development plans can be equally powerful when formal programs are not in place. Emerging leaders can be asked to do a self-rating using the competencies in the Nurse Manager Inventory (NMLC,2004). The nurse managers could also rate the nurses from their perspective. A gap analysis on a particular skill could lead to the development of an action plan to develop that needed competency. The following is an example of how this coaching might work in a clinical setting.
Kate Jones is a young, evening charge nurse in the Neonatal ICU. She has excellent clinical skills and is respected by her colleagues. She acknowledges that she is not inclusive in her decision making and is often judgmental about the viewpoints and contributions of others. Kate’s nurse manager views Kate as having high potential for a more significant leadership role. She is concerned, however, about Kate’s lack of tolerance of others and agrees that it could negatively impact Kate’s career if she does not commit to personal transformation. Both she and Kate are also aware that such behaviors do not support the development of a healthy work environment. They mutually develop an action plan with three components:
- Kate will read Marshall Goldman’s (2007) best selling book “What Got You Here Won’t Get You There.” Goldman pinpoints 20 bad habits that stifle successful careers and what leaders need to do to change them.
- Kate will ask her team members each evening for their input on decisions during her shift. She and her manager will have a short session each week to discuss her progress in being more inclusive.
- Kate will choose two team members with whom she can discuss her leadership goals. She will ask them for their honest feedback as they observe her interacting with others.
Domain Two - The Art of Leadership: Leading People
Emerging leaders must be taught that relationships live within the context of conversations that individuals have, or don’t have, with one another. Leadership is both an art and a science. The art of leadership involves managing relationships with others and influencing their behaviors. Casey Stengel, the beloved manager of many major league baseball teams, noted, from his own leadership career, that “Finding good players is easy. Getting them to play as a team is another story.” The same could be said of teams in healthcare settings. Guiding team members to get past their day-to-day problems, conflicts, and communication issues and more toward a goal of working as a high performance work team is a significant leadership challenge for emerging leaders. Yet the need to do this is critical in healthcare environments where team synergy and interdependence are required for high quality patient care. Developing the trust that is needed on teams begins with communication. Emerging leaders must be taught that relationships live within the context of conversations that individuals have, or don’t have, with one another. Excellent communication is a fundamental skill needed to effectively lead others. When developing emerging leaders, a self-rating on the Art of Leadership competencies in the Nurse Manager Inventory (NMLC,2004) is a good place to begin to identify strengths and weaknesses.
Often with novice leaders, structured techniques can help to promote better team relations by providing them with a shared simple set of words that describes critical communication behaviors. TeamSTEPPS TM is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and teamwork skills among healthcare professionals. It was developed for use in clinical practice with funding from the Agency for Healthcare Research and Quality. Tools in the model include the Two-Challenge Rule, Call-Outs, and Check-Backs (AHRQ, n.d.).
- The Two-Challenge Rule requires communicators to voice their concern at least twice to receive acknowledgment by the receiver. Emerging leaders can be encouraged to assertively practice this technique when they observe a deviation from standards of practice or witness unprofessional behavior.
- Call-Outs are a strategy that emerging leaders can be encouraged to use to inform all team members of crucial information during emergencies.
- Check-Backs require the sender of the communication to verify the information that is being received by the other team member. Emerging leaders can be encouraged to use check-backs to follow up on responsibilities that they delegate to others.
Leaders are also encouraged to use briefings, debriefings, and huddles to keep communication lines open throughout a shift. These tools and other information in the TeamSTEPPS program can be used to help emerging leaders improve their communication skills (Sherman & Eggenberger, 2009).
Developing the trust that is needed on teams begins with communication. Even in the most ideal of environments, communication breakdowns and conflict are inevitable on teams. If managed effectively by emerging leaders, these breakdowns can be viewed as an opportunity for team growth. Left unresolved, conflict can cause a loss of productive work time, medical errors, decreased patient satisfaction, staff turnover, and the development of an unhealthy work culture (Manion, 2005). In research conducted by Kramer et al. (2007) the ability to resolve conflict constructively was identified by staff nurses as one of nine supportive leadership behaviors that promote healthy work environments.
Emerging leaders often lack confidence in their ability to manage conflict. Real-time conflict situations offer excellent coaching opportunities for experienced leaders to work with novices. It can be helpful to present a structured approach to resolving conflict among team members. The following steps in the conflict resolution process can be used to help emerging leaders discuss and mediate conflicts that involve differences (Moss, 2005):
- Agree to ground rules for discussion that are acceptable to all parties, (examples of these rules might include one person talking at a time and length of meeting times).
- Allow emerging leaders to tell their story from their perspective.
- Highlight an overall goal that all team members value, such as providing the best care possible to our patients.
- Develop interventions collaboratively and agree to disagree on points of contention.
- Keep the lines of communication open and respect differences in attitudes, values, and behaviors.
Acknowledging the work and contributions of other staff members is a key leadership responsibility. Managing conflict well in an environment helps to create a culture where staff feel valued. AACN (2005) noted that recognition of the value and meaningfulness of one’s contribution to an organization’s work is a fundamental need and important for both professional and personal development. Acknowledging the work and contributions of other staff members is a key leadership responsibility. Emerging leaders can be coached to develop intentional behaviors that help to recognize the staff in their environments. This recognition could be as simple as a thank you at the end of a shift, or it might involve having the emerging leader nominate staff for organizational awards. The art of leadership can be nurtured and grown. Equally important in this turbulent healthcare environment is understanding the science of leadership as described below. Although healthcare is built around relationships, it is also a business that needs to be managed.
Domain Three - The Science of Leadership: Managing the Business
Although healthcare is built around relationships, it is also a business that needs to be managed. It is difficult to build healthy work environments in healthcare settings that are not financially stable. The recent U.S. debates on healthcare reform have focused on the cost of care in the US and have placed increasing pressure on leaders to operate organizations that are more efficient while continuing to improve quality and patient outcomes (Van Dyke, 2008). Golden (2008) noted that despite the need to become more financially savvy, current and emerging nurse leaders often gravitate to what they do best; and rarely does that include fiscal responsibilities. Novice leaders often fail to understand the impact of nursing activities and staffing on the revenue of a healthcare agency. If nurses are unable to see the financial ramifications and costs of decisions, they will be less successful in advocating for the resources needed to successfully staff and operate units.
A self-rating on the Science of Leadership competencies in the Nurse Manager Inventory (NMLC, 2004) is a good place for emerging leaders to begin to identify their strengths and weaknesses. Nurse managers are in a unique position to involve emerging leaders in the development and monitoring of a unit budget. For most units, staffing will be the single biggest budget item and area of concern. Emerging leaders can be involved in analyzing staffing grids and productivity reports. They can be given assignments to review staffing variances and create staffing alternatives. They can also be assigned to projects to elevate staff awareness about the costs of supplies and equipment. With the trend toward hospital reimbursement for performance measures that are nursing sensitive, emerging leaders need to understand how nursing care outcomes impact the financial bottom line of their institutions.
...emerging leaders need to understand how nursing care outcomes impact the financial bottom line of their institutions. The Healthcare Financial Management Association (HFMA) and the American Organization of Nurse Executives (AONE) co-publish a nursing-business newsletter, The Business of Caring. This newsletter can be downloaded for free and serves as an excellent resource to educate emerging leaders about business and finance. The articles and charts in the newsletter can be used for educational sessions. The Business of Caring features a Business School for Nurses as a regular educational section of the newsletter. Examples of recent topics include the following: reducing hospital readmissions, evaluating staffing costs, determining return on investment, business writing tips, medical variation, and the cost of care. This newsletter is a very rich source of business information and practical strategies that can be easily used by nursing leaders. The overall goal of all the activities described above should be to help emerging leaders develop confidence in their ability to build a business case to support their decisions.
Growing future nurse leaders is a long term quest that requires both planning and action. It is important to ensure that they develop the skills and competencies that will be needed for them to be successful. The development of healthy work places that are responsive to the ever-changing healthcare environment will be in their hands. Kouzes and Posner (2006), two well known leadership experts in the field of business, have noted that the most significant contribution today’s leaders can make for the future is develop their successors so that they will adapt, prosper, and grow. It is important for all nursing leaders to start now to groom our future leaders. These emerging leaders will ultimately replace them and continue the very important work that is being done to improve nursing work environments and most importantly patient outcomes.
Letter to the Editor by Jessica L. Smith
Rose Sherman, EdD, RN, NEA-BC, CNL
Dr. Rose Sherman is the Director of the Nursing Leadership Institute in the Christine E. Lynn College of Nursing at the Florida Atlantic University (FAU) where she is also an Associate Professor and Program Director of the Nursing Administration and new Clinical Nurse Leader tracks in the graduate nursing program. Prior to joining the faculty at FAU, Rose had a 25-year nursing leadership career with the Department of Veterans Affairs. She is widely published and speaks nationally on the topic of nursing leadership development.
Elizabeth Pross, PhD, RN
Dr Elizabeth (Beth) Pross is an Assistant Professor in the Christine E Lynn College of Nursing at the FAU. Beth has had 28 years of experience as a registered nurse, the last 11 years of which were in nursing education and administration. She currently serves as an appraiser for the American Nurses’ Credentialing Center Magnet Recognition Program® which she has done for the past 6 years. Her research interests include transforming health organizations through caring values and transformational leadership.
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© 2010 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2010