Reinventing Shared Leadership to Support Nursing’s Evolving
Role in Healthcare
T oday’s nurse leaders are confronted withunprecedented change. Healthcare reform, the Institute of Medicine’s report1 on the
future of nursing, fiscal constraints, and increased
expectations for quality outcomes are shaping our
environment in ways that few of us imaged even 5
years ago. To thrive in this brave new world of nurs-
ing and healthcare, nurse leaders need to develop
both a new vision and new approaches to create a
positive future.
www.nurseleader.com Nurse Leader 29
Jill K. Rogers, PhD, RN, NEA-BC
HISTORY AND BACKGROUND Involving nurses in decision making that affects their practice is a hallmark of Magnet® organizations and critical to achieving ongoing Magnet redesignation. At our Magnet-designated academic medical center, we recognized a need to reinvent our long-standing shared leadership process in order to respond to healthcare reform and the recommendations delineated in the Future of Nursing: Leading Change, Advancing Health.1
Shared leadership at our organization has been in place since 2002. The foundation of our structure and processes were the principles of partnership, equity, accountability, and owner- ship that Porter-O’Grady2 identified in his early seminal writ- ings on shared governance. In the years since inception, we have periodically reviewed our shared leadership structure and process, adding or eliminating committees, creating oversight processes, and monitoring outcomes to ensure success. The work of our committees has advanced our culture of nursing excellence and empowered our nurses to have a real voice in decision making that affects their practice. Our 2010 Magnet redesignation document featured numerous stories highlighting the outcomes of our committees’ work.
Despite these successes, however, our shared leadership committees seemed to lose focus in fiscal year (FY)2012. We were in the last year of a 3-year nursing strategic plan. Our strategic goals were largely accomplished, and the committees’ annual goals for the fiscal year weren’t robust and compelling. In addition, committee members were struggling to see the connection between their work and our overall organizational and nursing strategies. Significant time on committees’ agen- das was used for presentations from departments or individuals who wanted input on policy or equipment changes and new program initiatives. Most critically, chairs and director facilita- tors were seeing each committee’s work as separate and dis- tinct, rather than as integrated and synergistic. Clearly, it was time to revisit and reinvent our shared leadership structure and processes to prepare more strategically for the future.
ESTABLISHING THE FOUNDATION FOR CHANGE A critical first step in reinventing shared leadership was devel- oping a new 3-year nursing strategic plan. The process began with an environmental scan to determine critical inputs based on national, regional and local issues and agendas. Healthcare reform and the Institute of Medicine’s report1 as well as doc- uments from the American Organization of Nurse Executives (AONE), American Association of Colleges of Nursing (AACN), National Council of State Boards of Nursing (NCSBN), and other professional organizations and associa- tions informed our priorities. In addition, a small group of nurse leaders worked with our organization’s strategic plan- ning division to ensure that our priorities and strategies were linked to and advanced our organization-wide strategic plan. The director of strategic planning also interviewed several key nursing leaders, including our chief nurse executive, to ensure that all key inputs had been identified.
Once the core issues were surfaced, and an initial plan was drafted, the director of professional practice and development in collaboration with the organization’s director of strategic plan-
ning convened a group of frontline nurse leaders to provide feedback and further input regarding the strategic plan. These nurses represented practice areas across the organization. In addition, the majority were participants on shared leadership committees at the hospital-wide or departmental levels. Feedback from the group was incorporated into the final plan.
The strategic planning process identified 3 key areas of focus for nursing for the next 3 years: the care continuum; care invention, and the care profession. Each area supports our organizational and nursing efforts to prepare for health- care reform and advance the Institute of Medicine’s goals for nursing. Our care continuum strategy is focused on best practices in patient- and family-centered care, interprofes- sional collaboration, quality and safety initiatives, and nursing practice across the continuum. Care invention is focused on evidence-based practice, and the creation and dissemination of new knowledge through care redesign and evaluation, whereas our care profession strategy is focused on raising the bar of excellence for nurses through educational advance- ment, specialty certification, critical thinking, career develop- ment, and lifelong learning.
DEVELOPING A CONCEPTUAL FRAMEWORK FOR THE REDESIGN With the new strategic plan in place, our next step was to align our strategy, structures, and processes for shared leader- ship to facilitate positive outcomes. Magnet organizations are familiar with the structure, process, and outcome components of Donabedian’s model3 because these undergird the Magnet standards of performance. However, we believe that adding the component of strategy to the model further enhances our ability to stay focused on the big picture and drive to success- ful outcomes (Figure 1). The model has become one of the core conceptual frameworks that inform our work.
We used the components of the model (strategy, structure, process, and outcomes) in our redesign of shared leadership. The new structures and processes were developed based on our strategic plan. Committee structures were created to support the advancement of our strategy, and committee processes were designed to ensure that participants under- stood the strategy and maintained a clear line of site from strategy to their goals and the ongoing work of their com- mittees. Ultimately, the outcomes achieved by the commit- tees were intended to advance our care continuum, care invention, and care profession strategic goals.
KEY ELEMENTS OF THE REDESIGN The recent redesign of our organization’s shared leadership structure and process was the most extensive we have under- taken since its inception over 10 years ago. Five key elements of the redesign are described below. Highlights of the changes are shown in Figure 2.
1. Redesigned Chief Nurse Executive Council Focused on Strategy Historically, Chief Nurse Executive (CNE) Council had been focused on goal report outs and review of agendas for
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upcoming meetings. Following the redesign, however, CNE Council became a forum to bring together nurse leaders at all levels—the CNE, director, and manager facilitators and committee chairs—to focus on the national nursing agenda, our internal nursing strategic plan, and the annual commit- tee goals developed to advance the plan. Each month, the CNE or a designate starts the meeting with a strategy update highlighting a national agenda topic linked to one of our committee’s goals. The strategy update is followed by a presentation from one of the committee chairs linking their work to our organizational and nursing strategic plans and the annual goals they are working on to advance them. For example, when our Nursing Research and Evidence-Based Practice Committee presented their work, our CNE asked one of our nursing research consultants to present the national agenda for nursing research on her behalf. The consultant was able to define the national priorities and describe how the work that our nurses are doing is advanc- ing the national platform through evidence-based transla- tional research projects.
The heightened focus on strategy at the CNE Council has reinvigorated participants. They are connecting their work to our organizational and nursing strategic plans and also seeing how their work connects to national priorities. This link to strategy has given them a renewed sense that their work is meaningful and important to future success of the organiza- tion and the larger nursing profession.
2. Increased Prominence of Nursing Practice Committee as a Fulcrum for Change Prior to the redesign, the Nursing Professional Practice Committee (NPPC) was 1 of 7 shared leadership committees that were part of our structure. All committee chairs came to the CNE Council, but the committees themselves operated largely as independent entities. We made attempts to facilitate coordination and collaboration among the committees, but only achieved modest success.
With the redesign of our structure and process, we inten- tionally increased the prominence of the NPPC, viewing it as fulcrum for change. Of the 9 committees, subcommittees and taskforces that are part of the new structure, 6 report directly into the NPPC (Figure 3). In addition, the chairs of all 9 com- mittees sit on the NPPC as do the chairs of our 11 depart- mental nursing practice committees (DNPCs). The NPPC has direct oversight responsibility for the 3 standing sub – committees: Nursing Quality Peer Review, Nursing Policy and Procedure, and Nursing Performance, which is responsible for improving nursing performance related to quality, the patient experience, and financial targets in high-opportunity areas. The Practice Committee also provides oversight for annual task forces. These subcommittees and task forces for- mally report to NPPC monthly on their progress to goals.
The new structure and process has resulted in increased collaboration and coordination among the committees relat- ed to agendas, projects, and goals. NPPC meetings have become a forum for discussion and integration of agendas and projects across the committees.
3. Implemented Short-Term Task Forces to Advance New Initiatives One of the new elements added to our shared leadership structure and process was a series of task forces. These task forces, which report to the NPPC, are chartered annually. They are designed to meet for approximately 1 year, with a focused agenda designed to advance new initiatives linked to annual strategic goals. At the end of the year, the work of the task force is built into existing structures and processes to ensure that the work continues to advance.
Although the use of task forces per se is not new to our organization, their incorporation into our shared leadership structure and process is new. Traditionally, task forces have existed outside a defined reporting structure, and the team’s work is not typically visible to nonmembers until the task forces’ products are rolled out. The task forces that are part of shared leadership are highly visible at all levels of the organiza- tion, from the CNE to unit-based clinical nurses. Information is broadly shared and disseminated throughout the process, and nurses have opportunities to provide input and feedback to the task forces through their departmental representatives.
In FY2013, we launched 3 task forces: Genomics and Genetics Competency, Improving Geriatric Care, and Care Innovation. Each taskforce was linked to one of our strate- gic priorities and supported by an annual goal. For exam- ple, the Genomics and Genetics Competency Taskforce links to our care profession strategic initiative and was chartered to support our participation in a national research study on genomics competency sponsored by the NCSBN. Successful completion of the research study was one of our annual goals.
The primary aim of the study was to integrate genomic information into nursing care delivery. To accomplish this aim, task force members met with nurses at the unit level to determine their understanding of genomics and genetics, and developed an education plan that included grand rounds sessions, DNA Day education, e-mails, YouTube videos, and print materials. They also partnered with their shared leader- ship peers to ensure strong participation in the pre-test and post-test knowledge surveys that were part of the study. The
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Figure 1. Conceptual Framework
Adapted from Donabedian (1980)3
incorporation of the task force’s work into shared leadership process was instrumental in achieving a successful outcome.
4. Incorporated Innovative Process Redesign Techniques Into Committees’ Work Another key element of our new shared leadership process was the incorporation of innovative process redesign techniques into the committees’ work. Historically, our nurses used traditional approaches to manage the work of their committees. They dis- cussed initiatives during their meetings, assigned responsibilities for next steps, and came back together the following month to review progress. They also responded to frequent requests from other departments who wanted time on their agendas to present a new policy or process and get input from committee mem- bers. In the year prior to the redesign, it wasn’t uncommon to hear our chairs say, “We have so many guests coming to present today that we don’t have time for our own agenda items.” The new process put a stop to this practice.
Chairs were empowered to say no to requests for time on their agendas unless the request was linked to and would advance one of their annual goals. We also began to introduce our committees to innovative approaches to process redesign. The NPPC and Care Innovation Taskforce incorporated educa- tion into their meetings to learn techniques such as the deep dive and brainstorming. They subsequently began to use these techniques to redesign processes in support of their goals.
For example, the NPPC had a goal to identify 2 practice gaps in our Patient-Centered Care Model and implement at least 1 practice change to address these gaps by the end the year. Members chose to address the nursing bedside report process. Members rounded on the inpatient medical-surgical units 90 minutes prior to their meeting to observe bedside change of the shift report. Rather than using a checklist to audit the process, which would be the typical approach, they used a series of open-ended questions to help them understand bedside report from the end-users’ perspectives. They used questions such as, where were the nurses standing? How did the nurses
engage the patient? Did the patient participate and if so, how? They also spoke with nurses and patients about bedside report to understand their individual perspectives on the experience and what could be improved. They then spent their committee meeting discussing and processing their collective learning and developing guiding principles. In a subsequent meeting, they used a brainstorming process, called a gallery walk, to redesign bedside report. Committee members from various service lines were then engaged to roll out the process to their peers.
5. Structured Meetings to Enhance Collaboration and Communication Another component of the redesign was scheduling all shared leadership committee meetings on 1 day of the month. Although this had been our practice prior to the redesign, it became more important, and also more complicated, given the enhanced role of the NPPC. Chairs of hospital-wide committees and departmental nursing practice committees now needed to attend 5 hours of meetings on Committee Day. This entailed significant coordination for things such room scheduling, catering, and out of staffing time because most of the attendees have direct care responsibilities. From our perspective, the benefits gained from the enhanced com- munication and collaboration across the committees far out- weighed any logistical challenges experienced.
LESSONS LEARNED FROM THE REDESIGN The reinvented shared leadership structure and process was a great success from the end-users’ perspective. Chairs and committee members reported renewed engagement and excitement about our strategy, their goals, the process, and the opportunity to learn new and innovative ways of working. Our quantitative measure of success was to achieve at least 80% of the committees’ collective goals. The 9 committees, subcommittees, and task forces shared a total of 31 goals. They successfully accomplished 93% of these in the first year, exceeding their target by 13%.
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Figure 2. Traditional Versus Reinvented Structure
The new structure and process also resulted in important organizational learning. Key lessons learned from the experi- ence of our first year are discussed below.
Linking Strategy, Structure, and Process Yields Successful Outcomes Establishing clear and well-defined links between our strategy and the new shared leadership structure and process was the most important driver of success. The model provided the committees with a global positioning system (GPS) to keep them focused and on track for the year. The GPS also enabled the committees to course correct quickly and pre- vented them from distractions caused by requests for time on their committees’ agendas. Requests from various depart- ments were triaged to the director of professional practice and development so individuals could be referred to other decision-making groups to assist with their requests.
Clinical Nurses Need a Line of Sight to How Their Work Contributes to Organizational Strategy Nurses want and need to understand the strategy that informs and guides their work. Connection to a strategic national, organizational and nursing agenda has given our committees a renewed sense of meaning and purpose in their work. They have a line of sight to “the why” behind their goals—a line of sight that leads to the advancement of nursing at our organiza- tion and contributes to advancing the national agenda delin- eated in the 2010 Institute of Medicine report.1
Creating the line of sight to strategy is the responsibili- ty of nurse leaders. We need to be able to articulate the strategy, make it compelling to nurses at all levels, and identify regular opportunities to connect the dots from strategy to the work our nurses are doing, and ultimately, from their work back to the advancement of strategy. Our CNE Council strategy updates, committee goal report outs, and annual goal setting processes all create these opportunities for our nurses.
Learning New Ways of Working Requires Support and Education The use of innovative work redesign techniques took the out- comes achieved by our committees to a new level of excel- lence. However, given that nurses typically don’t learn these techniques in school, education in innovation and process redesign was a critical component of the committees’ work this year. Committee time was spent reviewing articles, watching videos, and developing plans for approaching goal accomplish- ment in new ways. We also partnered with our associate chief medical officer for innovation who provided an opportunity for several nurses to participate in a brainstorming session at a local innovation think tank. He also rounded with our Care Invention Taskforce co-chairs to gather information from patients, families, and interdisciplinary team members as part of an intended redesign of the discharge process.
All of these opportunities for education and application were critical in deepening our understanding of innovation and our ability to apply the techniques. That said, we have only begun to scratch the surface of the innovation knowl- edge base. In the coming year, we will hold a series of work- shops with an external consultant to further advance our capacity lead innovation. Attendees will include our nursing directors, managers, clinical coordinators, education coordina- tors and committee chairs. Our goal is to develop a group of innovation experts who can educate others and lead innova- tion efforts more broadly across the organization.
Implementing New Ways of Working Requires Resources Working in new and different ways, and developing creative approaches for meeting committee goals requires resources. Historically, our committee chairs received 8 hours monthly of non-direct time to support their roles. The 8 hours included committee day meetings and any required follow-ups. With the redesign of shared leadership, the needs of chairs and co-chairs,
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Figure 3. 2013 Shared Leadership Structure
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Reinventing Shared Leadership Continued from page 33
and in some cases, even committee members increased. Time was needed to observe processes and interview nurses, patients, families, and other caregivers as part of process redesign. In addition, chairs and co-chairs needed time to develop materials and follow up on necessary details between meetings.
To provide nurses with the resources needed for success, we increased the non-direct care time for the chairs from 8 to 12–16 hours per month. Allotted time was determined based on committee goals and current projects. We also ensured that each committee was supported by an adminis- trative assistant. This is typically the assistant of the director of nursing who serves as the committee or taskforce facilita- tor. The assistant takes minutes, coordinates room schedul- ing, and prepares materials. Such support is absolutely essential to ensure the success of frontline caregivers as they facilitate this sophisticated and important work.
Director and Manager Facilitators Play Essential Roles in Supporting Committee Chairs Although the goal of our shared leadership process is to pro- vide direct care nurses with opportunities for decision mak- ing that affects their practice, directors and managers also play a crucial role in the process. Each committee has an assigned director and manager whose roles are to facilitate the com- mittee’s work and support the chair and co-chair. The direc- tor facilitator ensures that committee members maintain a line of sight to the overarching strategy that guides their goals. The director also meets with the chair and manager facilitator monthly to plan the agenda, mentor the chair in meeting and project management, and review the status of goals. The manager facilitator provides support and guidance to the chair to ensure that progress is made toward goal accomplishment. The manager also provides ongoing tactical support to advance the committee’s work beyond what the chairs can provide given their available non-direct care time.
The outcome of this collaboration is partnership, equity, accountability, and ownership on the part of all participants. NL
References 1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing
Health. Washington, DC: The National Academies Press; 2010. 2. Porter-O’Grady T. Shared Governance Implementation Manual. Boston, MA:
Mosby; 1992. 3. Donabedian A. Methods for driving criteria for assessing the quality of
medical care. Med Care Rev.1980;37:653-698
Jill K. Rogers, PhD, RN, NEA-BC, is currently the vice president of Resident Care at Vi Living in Chicago, Illinois. She was the director of Professional Practice and Development at Northwestern Memorial Hospital when this article was written. She can be reached at [email protected].
1541-4612/2014 Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2014.01.010
mailto:[email protected]
Reinventing Shared Leadership to Support Nursing’s Evolving Role in Healthcare
HISTORY AND BACKGROUND
ESTABLISHING THE FOUNDATION FOR CHANGE
DEVELOPING A CONCEPTUAL FRAMEWORK FOR THE REDESIGN
KEY ELEMENTS OF THE REDESIGN
1. Redesigned Chief Nurse Executive Council Focused on Strategy
2. Increased Prominence of Nursing Practice Committee as a Fulcrum for Change
3. Implemented Short-Term Task Forces to Advance New Initiatives
4. Incorporated Innovative Process Redesign Techniques Into Committees’ Work
5. Structured Meetings to Enhance Collaboration and Communication
LESSONS LEARNED FROM THE REDESIGN
Linking Strategy, Structure, and Process Yields Successful Outcomes
Clinical Nurses Need a Line of Sight to How Their Work Contributes to Organizational Strategy
Learning New Ways of Working Requires Support and Education
Implementing New Ways of Working Requires Resources
Reinventing Shared Leadership
Director and Manager Facilitators Play Essential Roles in Supporting Committee Chairs
