1. Stuart, Wilma PhD, RN, NEA-BC
  2. Moore, Bridget DNP, RN, NEA-BC

Article Content

Nurse leaders are at the center of disruptive innovation in healthcare, and capable leaders are challenged to monitor a wide range of rapidly changing expectations. The American Organization of Nurse Executives released competencies for nurse executives that include detailed areas of focus in financial management, human resource management, strategic management, and information management and technology.1 As nurse leaders strive to manage competing priorities, polarity thinking can guide effective planning.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

This article introduces the basic concepts of polarities and polarity thinking, and examines the competing polarities of patient satisfaction and staff satisfaction. Additionally, the influences of empathy are considered in achieving a balance of the polarities through the relationship management competencies of collaboration, conflict resolution, and the creation of a trusting environment.1


The Triple Aim

Today's nurse leaders maintain an equity between consumer expectations, administrative organizational board expectations, and staff expectations. The Institute for Healthcare Improvement's (IHI) Triple Aim initiative asks healthcare facilities to clearly define patient-centered targets for the organization with a focus on improving the patient experience, population health, and the cost of care, all of which are interdependent.2Patient experience and patient satisfaction are often used as interchangeable terms, although patient satisfaction captures only parts of the patient experience.3 Measuring the patient experience has proven to be complex.3


One review illuminated the difficulty of measuring the patient experience and its relationship to patient satisfaction, describing the many influences on patient satisfaction, such as patient and family expectations, technology, care coordination, and the influence of caregivers.3 Although some aspects of patient satisfaction are subjective and difficult to accurately quantify, the review's author concluded that patient satisfaction measures do evaluate parts of the patient experience; however, there are multiple influences on patient satisfaction, including the staff work environment.3


Frontline staff members communicate that leadership expectations for higher patient satisfaction scores, in the absence of additional resources, have led to feelings of being stressed and overworked. In fact, staff member stress has reached such a level of concern that improving the work life of healthcare providers is now proposed by some as the "fourth aim" for healthcare improvement.4 In response to calls for a fourth aim, Derek Feeley, CEO of the IHI, urges providers not to lose sight of the goals of the Triple Aim; he acknowledges the interdependence of staff needs with the patient experience, but doesn't go so far as defining a fourth aim.5 He notes that if a fourth aim is needed to achieve the Triple Aim, such a change could be embraced at the organizational level.


The IHI acknowledges the importance of meeting the needs of healthcare staff with multiple resources available to assist healthcare organizations. However, questions remain; if the aim is to improve the patient experience, are patient satisfaction and staff satisfaction mutually exclusive? Is patient satisfaction or staff satisfaction an either/or question? Answers to this complex issue can be examined with the application of polarity thinking.



An unavoidable part of life, polarities are a pair of interdependent and mutually essential values that must be integrated into decision-making. If competing values on "each side" of a decision-making process could be argued to be correct and neither side alone is sufficient, this is likely to be a polarity. Polarities can't be solved with either/or thinking; they require both/and thinking, which may cause a paradigm shift from considering something as being either absolute "right" or "wrong."6 Terms such as paradox, dilemmas, and tensions may be used to describe polarities.7 Management of polarities should be on a continuum rather than treating them as problems with absolute answers.8 When comparing problems with polarities, problems are time limited, have an ending, and are solvable, whereas polarities are ongoing and aren't solvable.9


In a polarity, there must be balance. If one of the values in the polarity is emphasized at the expense of the other, new concerns can arise. Discernment of a polarity is key in planning how to balance, manage, or leverage the concerns, not abandon one issue for the other or waste resources trying to "solve" either.8


Polarity thinking is a framework for examining polarities through seeing, mapping, assessing, learning, and leveraging.9 The polarity thinking framework recognizes the importance of valuing and bringing balance to competing concepts. In response to the growing complexities of healthcare transformation, the Interprofessional Institute for Polarity Thinking in Healthcare was launched to guide others in understanding how to identify, map, and leverage polarities.10


As healthcare organizations strive to meet the holistic needs of patients combined with creating better healthcare outcomes, they're finding that solutions aren't simple. Implementing an electronic medical record was believed to be the key to advancing patient safety; however, most organizations could quickly relate stories of multiple challenges in such implementations. In fact, as healthcare organizations strive to improve patient satisfaction, some staff members begin to challenge the validity of the aim. Frustrated nonclinical board members are bewildered by why healthcare clinicians don't want to meet the needs of patients. Clinicians are frustrated by ever-increasing healthcare expectations. As tensions escalate, it's important to understand how to leverage polarities.


How do we know if we're dealing with a polarity or a problem? Quite simply: A problem can be solved; a polarity must be managed.9 There's a tension and an interdependence between polarities; however, they can never be either/or, and if one goes away, the other will be compromised. Traditional problem-solving skills may not be appropriate when dealing with a polarity. Leaders who can recognize the difference between problems and polarities provide a valuable skill set to the organization.11 Unfortunately, the saying "follow the money" may lead one to the polarity of patient satisfaction, where many providers find payments tied to satisfaction scores. Such an economic focus has driven the significant investment of resources to improve patient satisfaction scores, including hiring consultants, evolving new senior leadership roles focused on patient expectations, using software for tracking responses to patient requests, scripting staff responses, and publishing books on how to improve the patient experience.


As organizations continue to place a significant number of resources on one polarity (such as patient satisfaction), the resources targeted for the alternate polarity of staff satisfaction may be a lower priority. Prioritizing resources for a single polarity is rarely a wise business decision. One study found that hospitals and long-term-care centers with lower nurse satisfaction scores also had lower patient satisfaction scores (N = 95,499).12 In fact, for every 10% of nurses who reported job dissatisfaction, patient satisfaction scores decreased by 2% for willingness to refer others to the healthcare facility. The need for a focus on staff satisfaction is further evidenced by a progressively increasing nursing shortage as staff transition to lower risk and lower stress (emotionally and physically) roles outside the hospital setting.13,14


A growing crisis in healthcare communication

The emotional burden of empathetic caregiving can be exhausting, and support is needed for empathetic staff.15 Terms such as compassion fatigue, burnout, and stress abound in healthcare publications. A joint statement of the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine sounds an alarm for growing concerns surrounding caregiver burnout and identifies communication as a key component of future solutions.16


Healthcare continues to face challenges with patient safety and patient satisfaction scores, while staff members struggle with the stress associated with changing expectations. Leadership that conveys an empathetic understanding and supports frontline staff is essential to achieve future improvement in the areas of patient safety, patient satisfaction, and staff satisfaction.


Identifying staff needs

From a qualitative study of over 1,000 clinicians who were asked to describe what compassionate care for the caregiver would look like, six themes emerged:17


* We should acknowledge the complexity and gravity of the work provided by caregivers.


* It's the responsibility of management to provide support in the form of material, human, and emotional resources.


* Empathy and trust must be fostered and modeled.


* Teamwork is a vital component for success.


* Caregivers' perceptions of a positive work-life balance reduce compassion fatigue.


* Communication at all levels is foundational.



Further supporting this, a nationally recognized specialist in patient satisfaction data evaluated the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results with the National Database of Nursing Quality Indicators(R) nurse staffing and engagement results.12,18 Most nurses wouldn't be surprised to find the influence of nurse staffing on patient satisfaction. However, another key driver of patient satisfaction is the nursing work environment. In fact, if a facility has good staffing and a poor work environment, patient satisfaction scores are below the HCAHPS mean.


One study assessed standards for service delivery, supervisor support, coworker support, customer orientation, emotional exhaustion, empathetic concern, and job satisfaction for nurses (N = 159).19 Findings included an observation of a positive relationship between empathetic concern from the supervisor and customer orientation.


Clearly, patient satisfaction and staff satisfaction are polarities, and, as such, need equal resources and attention. However, many facilities focus greater resources on patient satisfaction and fewer resources on understanding how to care for the caregiver. One study reported that continued burnout in caregivers depletes staff members' ability to empathetically communicate with patients.20 In response to this growing recognition of the importance of meeting the needs of healthcare staff, the IHI recently published a framework for improving the joy in work.18 Four steps were proposed for leaders to create a path to joy in work. The first step focuses on asking staff members what matters to them; this implies listening and learning. At the core of the framework is an expectation that staff needs will be identified and addressed.


What's empathy?

An understanding of empathy can strengthen leader responses to staff concerns. Defining empathy can be elusive. The words empathy, sympathy, compassion, and caring are often used in similar ways but have different meanings. One author describes the contrast between sympathy and empathy as sharing a similar ability to completely grasp and internalize the feelings of another, but the act of empathy adds a dimension to distinguish a sense of separateness from the individual in distress.21 Another author describes feelings of empathy with such words as share, suffer, become "an insider," evaluate, and understand.22


Yet another author challenges many traditional definitions of empathy from a theoretical approach of hermeneutics.23 Described in the simplest of terms, the individual can't separate from his or her life history as he or she empathizes with another and can't make the experience of another his or her own.23 The definition of empathy can be simplified to "appropriate understanding of another human being."23 Empathy underpins many leadership theories and is included as a component of emotional intelligence, caring theories, and relationship theories.


Empathy and leadership

Empathy is identified as one of the key components of emotional intelligence.24 One author describes leadership empathy as a critical influence on staff retention, communication with teams, and increasing globalization.25 In a study of 1,241 nurses, a relationship was identified between leadership style and the work environment.26 Perceptions of resonant leadership, which has roots in both empathy and emotional intelligence, had a positive relationship with perceptions of staff empowerment and reduced perceptions of incivility and burnout.26 Although the role of empathy in patient care has been explored, there have been limited studies of the role of empathy in healthcare leadership communication. One study explored the relationship of authentic leadership to thriving in nursing staff and identified empathy as a mediator in staff vitality.27


Most nurse leaders can describe efforts to increase caregiver empathy to improve patient satisfaction scores. Are we equally adept at describing what empathy looks like in communication between leadership and staff? One author suggests "the content of the person's story is like watching a movie in black and white; listening for feeling adds the color."28 Do we see our staff in black and white or in color? Another author recommends that empathetic managers ask themselves if they know what their team fears, what they discuss when the manager isn't present, and if meetings allow time for discussion of how they feel about things.29


Empathy may not be valued by all leaders. A study of 87 business majors found that empathy was consistently rated as the lowest quality needed for leadership.30 As the findings were explored further, two themes emerged: 1) respondents believed that empathy is inappropriate in a business setting, and 2) respondents had a lack of familiarity with empathy.30


Leaders outside the healthcare field may also provide excellent examples of leadership empathy in action. One author identifies empathy in the work of the military in settings with substantial personal risk.31 He notes that military staff members care for one another to accomplish a mission, and the leader provides cover from above. At the end of the day, when military staff members are asked why they go the extra mile, they respond with "they would have done it for me." The author states that businesses today lack empathy and humanity.31 The absence of empathy in business settings results in staff members who become burned out as they go that extra mile for their clients if the leader isn't equally concerned for the well-being of his or her staff.


Addressing employee needs to improve satisfaction

As organizations consider steps to address patient satisfaction scores, identifying staff needs may be a critical first step. Using empathy to understand the needs of the other person places the leader in a position to effectively listen and find solutions. Solutions will be unique to the organization, but the common foundation is found in leadership empathy.


The Veterans Affairs Maryland Health Care System (VAMHCS) evaluated patient and staff satisfaction, and identified concerning gaps focused on areas of patient satisfaction and nursing turnover.32 In response, focus groups were held with patients and staff to understand these concerns. Focus groups allow leaders to listen to patients and staff before completing a strategy to address concerns. The VAMHCS team used the feedback from patients and staff to effectively target areas of need. Through their efforts, they brought the polarities into balance with significant improvements in both patient and staff satisfaction. The team developed a visual of a three-legged stool to explain that patient- and family-centered care are supported by the patient, the patient's family, and the VAMHCS staff. Like any stool, all three legs are important to achieve stability. Attempts to improve patient care requires understanding staff care.


Although there are many examples of efforts to improve patient satisfaction, organizations are beginning to appreciate the need to balance polarities. Examples of such awareness can be found in scorecards evaluated by all levels of the organization, which include metrics for patient and staff satisfaction. With an awareness of the interdependency of the polarities, the management team can address changes in one polarity with an anticipation that interventions may impact the other polarity. As leaders assess organizational polarities, leadership training may strengthen an understanding of polarities and how to achieve balance between competing interests. The good news is that empathy can be taught and should be included in leadership training.


In balance

As organizations strive to improve the patient experience, the strategy must include a balance between resources allocated for patient satisfaction and staff satisfaction. (See Figure 1.) When polarities are identified and one is out of balance, the other won't sustain for the long term without a correction in the balance; they're interdependent. A simple metaphor for opposing polarities is provided by the description of breathing.9,33 On one pole is inhaling and the opposite is exhaling; neither is sustainable without the tension and balance between the two.

Figure 1:. A balance... - Click to enlarge in new windowFigure 1:. A balanced strategy

The polarity thinking approach guides an examination of the two polarities of patient and staff satisfaction in healthcare. As indicators such as turnover signal a growing concern with staff satisfaction, leadership focus must be directed to this polarity, but not at the expense of the opposite pole, patient satisfaction. Empathetic leaders must effectively identify the concerns of their staff.


Football great Lou Holtz explains that all people ask three questions of their leaders:34


1. Can I trust you?


2. Are you committed?


3. Do you care about me?



Responses to these questions can be targeted by the healthcare leader with a goal of bringing the polarities into balance. Recognition of polarities through the lens of empathy provides opportunities for leadership to balance the needs of a complex work environment.


INSTRUCTIONS Communicating with empathy in a world of polarity conflict



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