1. Alexander, Susan DNP, ANP-BC, ADM-BC

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The delivery of high-quality patient-oriented healthcare is an ongoing need, changing rapidly and requiring flexible and talented leadership to navigate its many changes. Key to the implementation and success of these changes is the estimated 4.1 million professionally active nurses in 2017.1 In 2011, the Institute of Medicine, now known as the National Academy of Medicine, published its landmark report, The Future of Nursing: Leading Change and Advancing Health, addressing the critical role of nursing in improving accessible and high quality care for patients.2 The report discussed the need for a transformation in leadership, in which nurses would be "[horizontal ellipsis]full partners, with physicians and other health professionals, in redesigning health care in the United States."2(p33Dr) Despite the acknowledgement of the need for nursing's contribution and the responsibility for existing leaders to foster the growth of emerging leaders,3,4 barriers to the promotion of nurses into executive positions continue to exist. A recent survey of hospitals found that only 6% had nurses as board members.5 In the same survey, respondents identified the need for nurses to play a greater role in reducing medical errors, increasing quality care, increasing efficiency, and reducing costs, stating that nurses should have more of an impact in policy development and healthcare planning.6 How can nurses use history and expertise gained at the bedside to become key decision-makers in the boardroom? Nurses comprise the largest number of professionals in the healthcare workforce and are consistently rated as the most trusted profession.7 Why does their influence in practice environments continue to be limited? Finding answers to these questions began as a research interest and evolved into a global healthcare organization for 1 nurse who recognized the need for further study on how to help nurses exercise their skills to create a positive influence across organizations.



Jeffrey M. Adams, PhD, RN, NEA-BC, FAAN, began his career as a clinical informatics consultant in the early 1990s. While working with nurses and nurse executives in the implementation and on-boarding processes for clinical information systems, he quickly learned that these groups, who were expected to be skilled end users in practice, had little impact on selection or design of those systems. "I spent a lot of time with nurse executives and researchers trying to understand more about why they weren't influential in decision-making and discovered that nurse executives were not influential within their organizations on many topics" (Adams, phone communication, 2017). Working with colleagues including Joyce Clifford, PhD, RN, FAAN, Adams participated in research projects identifying the lack of influence as a shortcoming of many nurses, finding that "leadership is not a position or title, but rather leadership is behavior; how one acts, thinks, and communicates are all part of leadership and should be a part of every nurse's professional practice."8(p57)


Adams went on to complete doctoral studies at Boston College in 2008, studying the topic of executive influence in his dissertation. "We grew the idea that we need to see what leadership looks like," states Adams. In his studies, he constructed a conceptual model of influence, the Adams Influence Model (AIM), as a visual depiction of the interaction between the target of influence and the influence agent. "There is a huge turnover in nurse executive positions, with an average time in the position of 3 years. One of the reasons for this turnover is the difficulty in describing exactly what a "good leader looks like," says Adams, "there are components of what makes us influential [horizontal ellipsis] distinct factors and attributes we all have that can make us more or less influential." The AIM provides a framework for the development of influence in nursing leadership, linking the influence of nurses in leadership positions to the improvement of practice environments and empowerment of nurses to provide high-quality patient care.9



Throughout his career, Adams has served with leading healthcare institutions across the country, melding research, education, and practice as a consultant, nurse scientist, and faculty. He has worked with other researchers who share his interests in leadership and expanding the vision of enhancing the influence of nurses. Along with colleagues, Teri Pipe, Pat Reid-Ponte, and Jackie Somerville, the Workforce Outcomes Research Leadership Development (WORLD)-Institute was established. "We created the WORLD-Institute to be able to quantify and understand the influence of leadership in practice, academics, and professional organizations/associations; coordinate with other leading researchers across the country; and link it to outcomes to develop an empirical basis for nursing leadership enhancing their influence," states Adams.


Working with colleagues, Adams has developed 2 instruments based on the AIM to evaluate influence in nurses. The Leadership Influence over Professional Environment Scale was developed in his work with Massachusetts General Hospital, "because we know so much about the relationship linking positive practice/work environments for nurses and better outcomes for patients, clinicians, and organizations." Working with a cohort of peers as a Robert Wood Johnson Foundation Executive Nurse Fellow, Adams participated in developing an instrument entitled the Leadership Influence Self Assessment to "evaluate one's individual own strengths and opportunities for influence factor/attribute enhancement," states Adams, noting that the capacity to describe enhance these characteristics is of particular interest to individuals and the nursing profession as a whole. "In study after study, nurses are identified as the most trusted profession; at 3.6 million, nurses are larger in number than all other licensed healthcare provider groups combined, yet at the same time regularly fall near the bottom as a group (below patients) as our influence on health policy and other influence studies. For the health of our nation, this simply cannot continue, nurses have too much value and a purposeful approach to how we nurses as individuals and a profession can influence is an imperative."



Since the inception of AIM, Adams has published 2 additional models describing the interrelationships of leadership environments and outcomes for nurse executives and innovations in care delivery that can be used to frame policy initiatives. In 2015, Adams was inducted as a fellow to the American Academy of Nursing (AAN), and received an invitation to lead the AAN's Expert Panel on Building Exemplary Health Systems. At the Richmond Invitational Meeting, which focused on Executive Nurse Leadership and the Quadruple Aim, Adams was elected to serve as panel chairperson in 2016.



Although Adams will complete the Robert Wood Johnson Foundation nurse executive fellowship program this year, his commitment to enhancing the influence of nurses will continue. With colleagues Deb Zimmermann, Pam Cipriano, Sharon Pappas, and Joyce Batcheller, a series of publications and presentations from the Richmond Invitational Meeting will be shared later in 2017. The AAN Panel on Building Healthcare System Excellence has just recently adopted a purposeful approach to understanding and enhancing the influence of nurses and advancing the quadruple aim: enhancing patient experience, improving population health, reducing costs, and caring for the provider.10 Adams describes his continued interest in promoting the influence of nurses in professional environments, saying, "We need to focus on how we make practice environments better-accelerating innovations in access to care and quality of care. We need to understand how nurses go about influencing things."




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