Nursing leadership: Oxymoron or powerful force?
Savage, Constance M
The Voice of Ambulatory Care Nursing
Nursing leaders face many challenges on a daily basis. However, the fundamental challenge is addressing the impact of culture – societal, organizational, and professional that keeps nursing executives tied to the tactical when their energies should be directed to more long-term, strategic outcomes.
Cultural impact, combined with education and professional experience that emphasize a hands-on approach, surreptitiously works to incapacitate nursing leadership, threatening to transform the term “nursing leadership” into an oxymoron.
To ameliorate this situation, nursing leaders must shift focus from tactical to strategic, concentrating on the future state and the larger picture. To accomplish this, nursing leaders must build bench strength so their direct reports can act as fully functioning agents for nursing leadership. Further, nursing leaders must adopt a systems approach to better leverage the dynamics of interdependencies that are intrinsic to effective and efficient health care delivery.
Ultimately, nursing leadership must effectively transition from the operational (doing) aspect of work to the strategic (reflective) element of work by combining action and thought, thus making nursing leadership a force to be reckoned with.
Words that Collide
You’ve heard them before: “jumbo shrimp,” “working vacation,” “virtual reality.” They are oxymorons and they highlight the fundamental contradiction in common phrases. Stand-up comedians include them in their acts because the inherent irony in an oxymoron is good for a quick laugh.
Given the continuing crisis state of the health care industry, will “nursing leadership” become the newest oxymoron?
To avoid this dubious distinction, nursing leaders must take stock of what they are currently doing and redirect their energy as well as the energy of their staff members. But achieving this shift in awareness, attention, and action requires a brief examination of the factors influencing the dynamics of nursing leadership.
The Evolution of Nursing: Nature and Nurture
Nursing struggled with its professional identity long before Florence Nightingale arrived on the scene. In ancient Egypt, for example, slaves served as nurses, a stigma still subtly felt by Egyptian women who choose nursing as their profession. The situation was not much better in Florence Nightingale’s time when hospitals were squalid places and nurses were women who were not only untrained, but also often inebriated women of ill repute (Pulliam, 2003).
Based on her efforts and the efforts of the women who worked with her to provide aid and comfort to wounded soldiers during the Crimean War, Florence Nightingale became the icon for nursing – the individual recognized for elevating nursing to professional status. This rise in status, however, was not without cost. British military doctors did not welcome Florence and her compatriots; yet despite this hostility, she pushed on toward her goals to organize the care of the wounded and keep the field hospitals clean as a way to decrease unnecessary deaths.
Thus nursing as a profession was born in the social context of war, complete with its paternalistic, military hierarchy, within a society whose defining characteristic was, and still is to a great extent, a class system. The nature of a highly feminized profession emerged and was nurtured and shaped by the values (for better and worse) of its dominant male culture. Is it any wonder that struggling to find not only its voice, but its strength, is almost a part of nursing’s DNA?
Learned Incapacity: The Cultural Impact
The influence that culture exerts on nursing leadership has created a set of unspoken assumptions about the functioning and dynamics of nursing and nursing leadership. Whether its source is societal, organizational, or professional, culture shapes the assumptions, beliefs, behaviors, and actions of those who live and work within it (Schein, 1997). In the case of nursing leadership, these cultural sources have worked in concert to compound their influence and tacitly shape expectations and behavior. Consider the following story as a metaphor for the evolution of nursing leadership:
The average elephant weighs 16,500 pounds. Elephants are still used as beasts of burden in Africa and India. How are these massive creatures domesticated? Why don’t these animals break free from their captors? How is it that they are tamed and their strength and energies are harnessed? You would be surprised.
Young elephants are captured and separated from their mothers. A large, heavy rope or chain is attached to one of the animal’s legs; the other end is secured to a huge tree. The baby elephant fights to break free but cannot move very far; its leg is tied to the tree. Over time, the elephant learns it can’t break free and begins to struggle less. As the elephant becomes more docile, the massive rope around its leg is replaced with successively lighter weight ropes and these lighter ropes are secured to smaller and smaller trees.
As the elephant learns that it cannot break free and increasingly lighter weight ropes are secured to smaller trees, then small logs, the elephant “forgets” its strength and power. Eventually, the now mature, 8-ton elephant remains in place, tethered to a stick no bigger than your forearm by a rope the weight of an average dog’s leash. How can this be? The elephant learned to be incapacitated – unable to move or use its strength.
The same loss of might could be said about nursing leadership. The class system and the cultural values have been, metaphorically speaking, the rope and tree that have tethered the nursing profession, working hand in glove to incapacitate a powerful force. In some respects, nursing leadership has become debilitated by the organizational context in which it finds itself and must regain its strength in order to become a force to be reckoned with.
From Tactical to Strategic Focus
To regain nursing leadership’s strength, nursing leaders need to take a hard, objective look at what they are doing on the job. They can begin by answering this question: “On a weekly basis, what percentage of time do I spend putting out brush fires?” Leaders who spend more than 15% of their time dealing with crises – that is approximately 9 hours out of a 60-hour workweek – need to make a change. When nursing executives are responding to crises they are not leading.
Next question: How many of these brush fires does nursing actually own or are we functioning as the organizational “mop squad?”
One could argue that it’s hard to know where a “nursing” issue begins and ends but that is precisely the point. Because the basic mission or task of health care delivery requires a high degree of interdependency within the organization, problems are more likely to be systems issues versus divisional, departmental, or individual problems.
According to Russell Ackoff (1974), the nature of a system is that it consists of two or more elements, with each element having an effect on the whole. The elements in a system are interdependent and while the elements may reorganize themselves into a variety of subgroups, the subgroups will still be characterized by these properties:
1. Each has an effect on the whole.
2. No group has an independent state.
Not only does this describe the dynamics of health care delivery, it also sheds light on why so many re-engineering initiatives within nursing either failed or were fraught with problems. From a systems perspective, the entire health care delivery system would require re-engineering, not just nursing. Simply reengineering nursing turns a blind eye to the realities of interdependencies of health care delivery. Despite this knowledge, nursing is almost always considered either the source or the solution to problems within a health care organization.
Part of the difficulty arises from the nature of nursing itself. Nurses have primarily learned to respond to here-and-now stimuli – a patient in pain, checking clinical and vital signs, etc. In essence, years of clinical experience hone what would be referred to in business parlance as tactical skills. Compounding this is the culture of many health care organizations, which is characterized by responding to immediate and emergent issues.
Thus, leaders who have been practicing nurses are further reinforced to do what they know best. The press of the organizational culture pushes a nurse executive to address short-term emergencies at the expense of determining and following a long-term, strategic direction.
Therefore, in health care as in other industries, when bright, high-achieving, individual contributors are promoted to management and leadership positions, these individuals do what they do best: focus on daily operations or tactical issues.
At the management level, it is appropriate to focus on the tactical issues. However, if nursing executives stay in their comfort zone of the familiar hands-on daily operations, they will be giving short shrift to one of the key elements of their leadership role – strategic focus. And their nursing staff will pay the price for this crisis-management orientation, even if the nurse executive does not generate but merely responds to crises out of habit.
This is not to say that crises should go unaddressed. On the contrary, crises must be dealt with effectively and efficiently to ensure the well being of patients and to maintain quality and positive outcomes. The real challenge facing nursing executives is two-fold:
* Developing the proper “bench-strength” among direct reports so they can be deployed to problem-solve at the lowest appropriate level within the organization.
* Adopting a systems approach to change.
These two areas of focus form the foundation for a nursing leader to create and sustain a strategic focus; in essence, they address daily operating issues in such a way that they “buy time” for the nursing executive to focus on strategic goals.
Bench Strength: Savvy Leader’s Best Friend
Borrowing a concept from sports and applying it to nursing, bench strength simply means that the nurse leader’s “players” are versatile enough to be used in several different positions and “cross-trained” to be effective substitutes when called upon to fill in.
In business, bench strength is linked to strategy in that it provides a contingency plan to keep on with “business as usual” when life throws a curve ball, or more realistically, when your valued staff members become ill, take vacation, or accept a job in a different department or organization. No leader should ever allow a solitary staff member to be the only individual who knows, understands, or manages information or processes that are vital to organizational functioning. Nor should a leader tolerate projects being put on hold, decisions being delayed or problems going unsolved because a key staff member is on vacation or unavailable. Savvy leaders insist on bench strength to provide backup.
To develop bench strength, begin with your direct reports. First, reassess their core competencies to ensure that they can effectively and efficiently handle crises, speaking and acting competently as your agent. To effectively assess your direct reports, forego the checklist approach that has become such a popular and timesaving, albeit questionable, mechanism for “assessing” competencies.
That being said, you should still list the skills, abilities, and knowledge that you consider essential for your staff to demonstrate if they are to speak and act on your behalf when tactical issues are raised. Prioritize the list from most to least critical. Use the list as a reference guide when you both observe your staff exhibiting behavior-based competencies and provide them with feedback regarding their performance.
For example, replace the all-inclusive “Communicates effectively” with the more behaviorally based “Effectively uses active listening by:”
1. Accurately identifying the emotional and content message delivered by sender
2. Paraphrasing the ‘heard’ message to the sender
3. Responding appropriately and effectively to the sender’s feedback about the paraphrased message
Generally speaking, nurse executives wishing to focus more on the strategic and less on the tactical should focus on competencies for their direct reports that include the following:
* Active listening
* Assertive communication and behavior
* Appropriate selection and use of conflict-handling modes
* Political savvy (including recognizing and effectively using power)
* Negotiation skills
* Innovative problem solving
* Short- and long-term planning
* Effective networking
These core competencies for nursing leaders’ direct reports are the basic building blocks for organizational and professional success. Prioritizing these competencies according to the unique challenges of one’s organizational culture will help direct reports focus on the skills and behaviors with the most “organizational pay-off.”
Bench strength can be developed in a variety of ways. Identifying people who exhibit desired behaviors and using them as role models is one method. Post-meeting debriefings to discuss how effectively situations were handled and exploring options to employ in the future is another way to develop competencies. Individual coaching is another time efficient and effective way to build competencies. Whatever the approach, an emphasis on experiential learning, in which individuals actually practice the behaviors associated with the competency and receive feedback to help them calibrate their performance, is essential for mastery.
Taking a Systems Approach
Probably the greatest challenge nursing leaders face is persuading fellow leaders to take a systems approach to health care delivery. The interdependences at play in health care delivery explain why nursing will never be able to “fix” problems that are inevitably traced back to nursing. But before helping others see the light, nursing leaders should be certain that their houses are in order.
For example, the long-standing distinction between inpatient and ambulatory care nursing – where is it written that this separation should exist? Most recipients of health care services unconsciously pray that they stay on the ambulatory side of the fence, since the prospect of hospitalization usually signals serious health concerns, be they acute or chronic. From a strategic continuum-of-care perspective, actively managing both the ambulatory and hospital sides of nursing can ultimately build a stronger power base for nursing executives. Yet nursing leaders often focus the bulk of their time and attention on inpatient nursing and assume (or hope) that ambulatory nursing will take care of itself.
Taking a systems approach means looking at things within context. Systems thinking is expansionistic versus reductionistic. Whether you use the metaphor of analog versus digital clocks or osteopathic versus allopathic medicine, the key to understanding systems thinking is to first appreciate the issue or situation at hand within its context. Understanding the factors that impinge on an issue opens up a wider range of possible resolutions to the problem.
In contrast, our typical analytic, reductionistic thinking takes problems apart into smaller and smaller units of analysis in the hope of finding “what is wrong” and fixing it when in reality “what is wrong” has more to do with the failure to emphasize and improve the interdependency which is at the core of all systems. Thus, addressing a “nursing” issue can be an exercise in futility. Situations that are labeled, as “nursing issues” are often circumstances in which the failure of the interdependencies becomes apparent because the buck stops, so to speak, with nursing.
Nursing executives who embrace a systems approach will be less likely to assume ownership for problems without first encouraging their colleagues to look at the issue within its context. This may mean exploring the impact of physician behavior on the problem. It may mean pushing to include physician practice patterns as part of a solution. It may mean gaining insight into the need for consistency from leadership throughout the organization. It might be just the thing to successfully leverage the argument that the survival of a healthcare organization rests with ability of its leaders to forsake old, ineffective and mindless patterns of affixing blame for problems and take on the challenge of understanding how to make things work more effectively and efficiently.
Putting it All Together: Act ‘Thinkingly’
To make the shift from tactical to strategic focus, nurse executives must realize that they, as “…people in organizations should be more self-conscious about and spend more time reflecting on the actual things they do” (Weick, 1979, p. 168). In essence, they need to act ‘thinkingly.’ No, this isn’t another oxymoron; it is an acknowledgment that we create our own environments. Weick, paraphrasing Braybrooke, captures the notion of the enactment of experience this way:
“Experience is the consequence of activity. The manager literally wades into the swarm of “events” that surround him and actively tries to unrandomize them and impose some order. The manager acts physically in the environment, attends to some of it, ignores most of it, talks to other people about what they see and are doing.” (Weick, 1979, p.148)
In essence, what we do at work (our actions) actually shapes the organization’s environment. Thus, if nurse executives actually do more tactical than strategic things, then the reactive crisis mode will be their reality. Combining reflection with action will impact the organizational environment by shaping it in a different way. Shifting to a future focus and aligning actions with that future state, nursing leaders will begin to move out of the tactical and into the much needed strategic focus. Balancing action with reflection modulates nursing executives’ penchant for action with the necessity of being mindful or thoughtful.
To act thinkingly is to move out of the reactive, tactical response mode and focus on the bigger picture. It is the key to making the transition from the tactical to the strategic. In order to accomplish this, a nursing executive should be able to clearly articulate her/his responses to the following questions:
* What is my strategic focus for nursing within our organization?
* What are my strategic goals?
* How do I measure progress toward these goals?
* How do I keep my strategic goals in the forefront of my primary organizational interactions?
In simplest terms, a strategic focus should identify an ideal state in light of the current existing state. Perhaps you want to be the employer of choice in your area. Maybe you want to promote nursing research that reflects innovative care techniques. Whatever the focus, it should take into consideration from both a business and people perspective what “could be.” Stronger nurse-physician partnerships, more cost-effective care delivery, reduced waste, increased efficiency, more satisfied staff, or higher retention rates – a strategic focus considers the context in which your organization exists and aims at creating that distinctive difference which promotes organizational health.
Once a strategic focus is clear, developing strategic goals is the next task. To simplify what can appear an odious task, use the back-planning model. Back-planning is merely a method of starting with the end result, in this case the strategic focus, and working back from that point toward the current state. Think of the steps involved in planning Thanksgiving dinner. If dinner is to be served at 6 pm, what is the next step back? In this case it would mean taking the thoroughly cooked turkey out of the oven at 5:45 pm to rest before carving. The next step back would involve cooking time, which would be contingent upon the weight of the turkey. Next step back? Thawing the turkey. Don’t know enough about cooking a turkey to make a realistic plan? Then talk to seasoned experts and learn. Ultimately, the plan for Thanksgiving dinner would develop as a timeline of critical incidents, actions, and outcomes.
Some leaders’ strategic goals incorporate measurements, others require an additional step to ensure that there is some valid way to measure progress and outcomes. In either case, the measurements are the mechanism to both stay focused and stimulate action. Maintaining a strategic focus in a reactive environment is a struggle. However, nursing leaders must devise ways to keep their attention trained on their strategic goals.
One exceptionally high-impact health care executive maintained his strategic focus on improving customer service in this way: he kept his desk clear and under the protective glass desk topper he inserted two signs, both with the same message. One sign faced him; the other faced whoever was sitting opposite him at his desk. The sign read simply: “If you’re not serving the customer, you’d better be serving someone who is.” This was his mantra, so to speak, that kept him focused before, during and after his interactions with others. He made sure that each of his exchanges with staff and employees incorporated some aspect of customer service, whether it was the service standards he modeled through his behavior, a clear organizational strategy to improve service, or a change in organizational policy that would affect employee morale, subsequently having an impact on customer service.
Nursing leaders can leverage significant change within their organizations – if they choose to break free of the cultural expectations and habitual behaviors that often chain them to unsatisfying, grinding work. As nursing leaders assert themselves and leverage their sense-making abilities to inject a worldview that honors interdependencies, they will more clearly recognize how they shape their reality. And as nursing leaders stretch their personal comfort zones they will begin to shape the reality of their staffers as well. Imagine an organization in which:
“…Endless discussion of questions about whether we see things the way they really are, whether we are right, or whether something is true will be replaced by discussions that can focus on questions such as ‘What did we do?’ ‘What senses can we make of those actions?’ ‘What next steps best preserves our options and does least damage to our repertoire…'”
(Weick, 1979, p. 169).
As nurse executives take on the challenge of saying “no” to crisis management, elevate their business acumen, and focus energy on their strategic goals, nursing leadership will, in fact, become a force to be reckoned with.
Ackoff, R. L. (1974). Redesigning the future: A systems approach to societal problems. New York: Wiley.
Pulliam, D. (2003). [On-line.] Available: http://womenshistory.about.com/library/prm/blladywiththelamp1.htm.
Schein, E. (1997). Organizational culture and leadership. San Francisco: Jossey-Bass.
Weick, K. (1979). The Social Psychology of Organizing. Reading, MA: Addison-Wesley.
Constance M. Savage, PhD
Constance M. Savage, PhD, is Assistant Professor, Richard E. and Sandra J. Dauch College of Business and Economics, Ashland University, Ashland, OH.
Copyright American Academy of Ambulatory Care Nursing Jul/Aug 2003
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