Nursing Center - Journal Article

Keywords: decision making, leadership attributes, Magnet journey, organizational excellence

Abstract

The chief nursing officer is in a unique position to guide his or her organization to excellence by creating a compelling vision; maintaining objectivity regarding the nursing department's accomplishments; holding senior nurse leaders accountable as Magnet champions; demonstrating strategic thinking, business planning development, operational connection, and awareness of clinical aspects of care; and establishing levels of ownership and decision making within the nursing department's operational framework. The clear definition of terms including responsibility, authority, delegation, accountability, and empowerment are necessary and, coupled with specific actions, skills, and measures of success, guide individual and group processes to achieve organizational excellence and ultimately Magnet designation.

NURSE EXECUTIVES, leaders, and staff nurses all desire recognition for the quality of patient care, the professional work environment, and the collaborative practices they have established with colleagues in their organizations. These elements are differentiators in today's competitive environment, and the organizations' ability to attract and retain the best and brightest depends on leadership's responsiveness in addressing these evidence-based elements that comprise the forces of magnetism.1 However, in the quest to seek recognition, sources of evidence that are required in the Magnet application may be missing within the organization and will serve as gaps or areas of weakness to be addressed before Magnet designation can be successfully achieved.

This article will highlight leadership considerations and opportunities for improvement along the path to organizational excellence and recognition of excellence via Magnet designation. Considerations are predominately related to the chief nursing officer (CNO) and include creating a compelling vision; maintaining objectivity regarding the nursing department's accomplishments; holding senior nurse leaders accountable as Magnet champions; demonstrating strategic thinking, business planning development, operational connection, and awareness of clinical aspects of care; and establishing levels of ownership and decision making within the nursing department's operational framework.

PURSUING MAGNET DESIGNATION: LEADERSHIP MATTERS

Creating a compelling vision

Steinbinder and Scherer 2 conducted 10 in-depth interviews of CNOs of Magnet organizations. These CNOs consistently identified nursing leadership as the key ingredient in successfully attaining Magnet designation, as the Magnet journey is a reflection of the senior nursing leader's ability to share a compelling vision of the future state of nursing practice within the organization. An effective vision evokes positive, visceral responses from the organization's nursing community. Along with the vision, the CNO's ability to articulate a clear, meaningful plan to achieve the vision provides direction, communicates conviction, and begins shaping the journey. Although oratory eloquence is not required, the CNO's passion for the topic and a clear, succinct presentation style is necessary to communicate the relevance of the work ahead and the level of commitment needed to achieve Magnet designation. If inspiring presentation skills are not among the CNO's acumen, he or she would benefit from polishing those skills and may consider joining a public speaking organization such as Toastmasters.

Communicating the vision and the plan

One way to engage the various stakeholders is by using elevator speeches. Elevator speeches are brief, targeted explanations that can be delivered in less than a minute during informal, chance encounters with stakeholders. Communicating the purpose of the Magnet journey, what will be achieved as a result of attaining Magnet designation, and, most importantly, what the CNO specifically needs from each stakeholder including active, collegial participation in various committee and council activity prepares individuals and groups to anticipate steps of the journey.

The CNO's ability to juggle a wide array of organizational accountabilities, nursing specific actions, and regulatory and operational activities while maintaining a focus on the Magnet journey requires conscious awareness, dogged determination, and the skill to connect activities of daily and strategic work to the Magnet forces.

Maintaining objectivity

One CNO who has been in a Magnet organization for several years shared that maintaining her objectivity through the application process was critical yet exceedingly difficult. As she reflected on her personal experience, she realized that in the spirit of shared decision making, she had delegated the work of writing the Magnet application to leaders within her organization. She had grown comfortable with her nursing department's progress and was lulled into a false sense of security about the caliber of the work accomplished to date. It was only through dialogue with a group of Magnet appraisers that she recognized her loss of objectivity.

Weick,3 who studied high-reliability organizations, explained that leaders who are preoccupied with failure focus on the subtle signs that may indicate that something is wrong. CNOs who search for repeated patterns signaling that a program, system, or process is not working as intended will preserve their objectivity and ability to course-correct quickly. This preoccupation with failure will ensure that the CNO maintains objectivity along the way.

CNOs must also maintain a sense of objectivity regarding performance of senior nursing leaders within the organization. Does each leader embrace the Magnet journey? Is there evidence that each leader provides staff the opportunity to fully participate in unit-based activities? Are clinical nurses knowledgeable about clinical issues and are they involved in various aspects of the quality improvement process? Do nurse satisfaction scores reflect that the unit's work environment is conducive to professional practice? Is the unit-based shared leadership structure robust and dynamic? Are mechanisms in place to maintain open 2-way communication? If CNOs cannot answer yes for each senior nursing leader's units of responsibility, what is the CNO doing to either engage the leader who is not demonstrating Magnet champion behavior or coach the individual to enhance desired behavior?

One CNO of a large Magnet facility who is preparing documentation for redesignation does have a nurse leader who has not been a Magnet champion, but who has great potential. This CNO has given this nursing director an assignment of developing the project plan and overseeing the application development process. This task requires hands-on involvement, which will result in her being an expert on the forces of magnetism. The assignment is a win-win for both CNO and leader as the leader will use her exceptional project management skills, and the CNO will be assured that the application is complete and ready by deadline and that the director has contributed to each force of magnetism.

In the event that the CNO does not have confidence that a senior nurse leader can become a Magnet champion, the choice is either to actively transition the person from the leadership role or to resign oneself to the reality that Magnet designation is a slim possibility. Magnet appraisers actively search for pockets of average or mediocre performance in the midst of excellence. Warning signs for appraisers include a lack of exemplars from specific units in the application, average to poor performance on nurse sensitive indicators and patient satisfaction results, high nursing turnover, high vacancy rates, lack of evidence of an engaged unit-based shared leadership council, recent turnover of nursing leadership, vague or basic performance improvement activities, and consistently greater than 100% productivity. These red flags signal that excellence is absent and may result in scores that do not fall within the range of excellence for various forces of magnetism, which ultimately may prevent the entire organization from receiving a site visit to verify, clarify, and amplify the forces of magnetism.

Mastery of business planning

The CNO serves as a role model by actively demonstrating strategic thinking, financial acumen, operational connection, and awareness of clinical aspects of care. Business plan development and presentation of the plan is a skill that CNOs use regularly on the road to Magnet designation, as innovative approaches to care delivery and professional practice are hallmarks of excellence. For example, to meet an identified need for a new program, equipment, or system, the following elements should be considered in developing the business plan: (1) a review of the literature and market analysis; (2) a description of the product, service, or program; (3) a statement of the problem and the associated solution being proposed; (4) a description of the benefits to patients, nurses, or other customers and expected results; (5) the organizational structure that will support this new service, product, or program; (6) the funding requested to implement the new program, service, or product; (7) the financial projections including funding amount and analysis of financial information; and (8) if a smaller scale pilot is warranted, include evaluation metrics and funding necessary to implement the pilot. Sound business plans reflect that the senior leader has fully researched and prepared to address financial, operational, and programmatic issues in a manner that is aligned with the organization's mission and direction. Implementing innovative programs and projects is vital for organizations seeking Magnet designation, as well-orchestrated innovation is a hallmark of a Magnet environment.

Mastery of strategic planning

Strategic planning is essential to identify priorities, align them with overall organizational key strategies, and formalize the map on the road to Magnet designation. By involving clinical nurses, educators, formal leaders, and informal leaders, the CNO engages the nursing community to create an exciting future. Operationalizing the plan is the active process of bringing the future into the present. Successful CNOs and nurse leaders have mastered the skill of large-scale involvement, which results in commitment and ultimately effectiveness once the plan is fully implemented. Using planning processes with positive, energizing facilitation methods such as appreciative inquiry 4 allows many participants to actively engage in designing and ultimately implementing the plan. Other methods such as future search5 and open space technology6 are just as flexible facilitation processes that can lead to powerful, positive outcomes.

Demonstrated financial performance

Mastery of financial acumen is essential for CNO success. Being able to deliver on one's promise--and meeting the budget is the CNO's promise--earns the CNO the respect and confidence of members of the executive team as well as the board of directors. The CNO is responsible to be a steward of the organization's finite resources and by meeting financial targets, the CNO positions himself or herself to gain support for innovative program proposals, expensive technology to support nursing practice, and new services that impact the organization's bottom line.

Demonstrating operational connection and awareness of clinical care

Demonstrating operational savvy communicates the CNO's ability to manage day-to-day hospital activity while maintaining a broad perspective of the nursing department's direction. Weick uses the phrase "sensitivity to operations" to describe the need for leaders to attend to the front line and to be knowledgeable about how the work is getting done by staff. CNOs and all levels of nursing leaders must learn the skill of situational awareness, to be in tune with all facets of the nursing operations in the moment. Maintaining sensitivity to operations requires consistent, frequent rounds of all areas where nursing is practiced. Leaders who observe workflows and patient flow, who ask staff questions regarding barriers to care delivery, and who recognize the quality of nurse-physician, nurse-manager, and other nurse relationships are better prepared to address problems before they result in catastrophes.

CNOs and nurse leaders are not required to be clinical experts; however, they are expected to hire clinicians who have recognized expertise. In addition, nurse leaders should provide forums for clinical nurses to address clinical issues and participate in decisions that impact patient care. Nurse leaders' ability to guide clinical decision making using an inquiry approach allows clinicians to demonstrate control over practice and to articulate sound, preferably evidence-based rationale for their decisions.

FROM DEFINITIONS TO OUTCOMES: AN ORGANIZATIONAL FRAMEWORK

Levels of ownership and decision making are areas of confusion that cause detours along the road to Magnet designation. CNOs and nurse leaders believe that a culture of empowerment promotes a more highly engaged workforce. However, in their quest to design and implement shared leadership/governance structures within the organization, clear definition of terms including responsibility, authority, delegation, and empowerment are often missing or vague. These definitions, coupled with specific actions, skills, and measures of success, are necessary to guide individual and group processes within the organization's nursing community. Table 1 provides simple definitions and suggested actions that illustrate how each term can be applied within the nursing department. Defining and differentiating each term, its relationship to enhanced work environments, and specific actions related to each term assist leaders and staff in integrating a consistent approach throughout the nursing organization. Based on the research of Laschinger et al,11 enhanced work environments characterized by empowerment demonstrate higher perceptions of autonomy, control over nursing, and positive nurse-physician relationships, which are essential attributes of a Magnet culture.

Table 1 - Click to enlarge in new window

Table 1. Defining and identifying actions: Authority, accountability, responsibility, delegation, and empowerment

Figure 1 illustrates the relationship of accountability, responsibility, authority, delegation, and empowerment in a shared leadership environment. The roles of the CNO, senior nurse leaders, unit-level nurse managers, advance practice nurses, and clinical nurses have clear and distinct boundaries, yet, when performed as designed, result in a synergy that promotes the goals of the organization as well as the individuals.

Figure 1 - Click to enlarge in new window

Figure 1. Accountability pyramid. CNO indicates chief nursing officer.

SUMMARY

Leadership matters. The road to organizational excellence is fraught with detours, ambiguities, and barriers, yet it is also paved with signals, signs, and structures that equip CNOs, nurse leaders, and clinical nurses with valuable tools to stay the course and reach their destination of Magnet designation. This designation allows participants time to showcase their accomplishments, celebrate their successes, and receive accolades from peers, the organization, and the community before embarking on the next leg of their journey that is to sustain and then attain higher levels of excellence. The CNO is in the unique position to forge new paths and create an even more compelling tomorrow. Magnet designation is not possible without the contributions and leadership of the CNO.

REFERENCES

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