Is yours a nurse-led hospital?

Two nurse leaders discuss the obstacles holding nurses back from leadership roles, the perception of nursing versus its reality, and how patients can tell the difference between hospitals where nurse leadership is strong versus those where nurses are less empowered.

There are approximately 3.5 million nurses, including registered nurses, advanced practice RNs and licensed practical nurses, in the United States. This makes the nursing profession the largest segment of the country's healthcare workforce.

There's power in numbers, so to say, but nurses also have a great amount of influence over clinical outcomes, patient satisfaction and employee engagement in hospitals.

The role of the nurse is also a culturally significant one. Last year, Americans ranked the nursing profession as most honest and ethical. In fact, 80 percent of Americans said nurses have "very high" or "high" standards of honesty and ethics, while 65 percent said the same for physicians.

Despite the fundamental role nurses play in healthcare, they still face underrepresentation in healthcare decision-making and leadership. The Institute of Medicine released its recommendations in "The Future of Nursing: Leading Change, Advancing Health" approximately five years ago, including the recommendation that nurses be full partners with physicians and other health care professionals in redesigning healthcare. There is still some way to go, as experts below will attest. Nurses still make up a small percentage hospital board members, for instance.(1)

Nancy J. Robert, PhD, MBA, BSN, is executive vice president and chief product and marketing officer for the American Nurses Association, the only full-service professional organization representing nurses through constituent and state nurses associations. Christy Davidson, DNP, RNC-OB, is the interim dean of the School of Nursing and Health Sciences at Capella University, which offers online nursing degree programs and is a partner for the ANA Leadership Institute.

Here, Dr. Robert and Dr. Davidson discuss some of the obstacles holding nurses back from leadership roles, the perception of nursing versus its reality, and how patients can tell the difference between hospitals where nurse leadership is strong versus those where nurses are less empowered.

Question: "Physician-led" is a common phrase to describe healthcare delivery and hospital cultures. Do you think "nurse-led" needs to be part of that discussion, too? How, if at all, should hospital and health system leaders reframe their understanding of nurse leadership?

Christy Davidson: As our profession continues to evolve, I think nurse-led healthcare is really on the horizon. Recommendations from The Institute of Medicine Future of Nursing Report, such as explaining opportunities for nurses to lead, collaborative improvement efforts and encouraging nurses to branch out, are fostering either nurse-led hospitals or at least places where nurses are full partners in leadership. We have data that supports advanced practice nurses' ability to improve outcomes. As we evolve, why would we not want to be open to the idea of nurse leaders being full partners in leading healthcare organizations?



Nancy Robert: Research published in the Journal of Healthcare Management, a survey of 1,000 hospital boards found only 6 percent of board members are nurses.(1) Board governance makes decisions about the values of an organization and the products and programs that get funded. There is work from another researcher that suggests [the leadership discrepancy is] gender-biased, and there is a totally outdated perception of nurse leadership skills. Then you go to Gallup, the opinion leaders' poll, and nurses are seldom viewed as leaders in the development of healthcare systems and delivery.(2)

What's the greatest barrier? Nurses not being seen as important decision-makers compared to physicians. That's changing, but those perceptions are still out there. There's the perception versus what is really going on. I think we need to make a big, big drive to educate people and counteract those perceptions.

Q: Can you describe a hospital where nurse leadership is strong and intrinsic versus one where nurses are less empowered?

CD: When you have strong nursing leadership in an organization — and I'm thinking broadly, among all levels of nursing — a lot of times that is demonstrated by nurses who are interested and engaged in lifelong learning. The organization makes efforts to support this. Nurses take ownership of projects, they are involved in decision-making and governance, and they have a voice. The nurses search for solutions and they work effectively and cross-functionally across departments.

When you have nurse leadership that is not quite as strong, you'll see nurses working on units as efficient task-doers, but maybe they don't embrace the opportunity to be a leader. If they identify an issue, they will wait for resolutions. They might be informed about decisions, but they aren't really involved in the decision-making process. They work in silos.

NR: There is a ton of research in this area, and it tends to fall under the broad headings of transformational versus transactional leadership. When you have relationship-based leadership, you open up and leverage the talents of every one, down to every nurse who interacts with patients at the bedside. You have more engaged nurses, nurse turnover tends to diminish, and you have an environment where people say what they mean and mean what they say. You have a lot of positive reinforcement.

When you look at nurse burnout and retention issues, many times it gets down to issues of, "I'm not heard. We don't have shared values. I can't positively influence care at the bedside." Transformational leadership lets nurses at every level participate. Vendors and people who support different hospital systems have told us that, as they walk through a hospital, they see the difference in the way things are managed. Is there a strong nursing-centered leader, or is it someone who is more transactional?

Q: Can patients tell the difference between the two settings you described above?

CD: It's palpable, it really is. When you have an organization with strong nurse leadership, you are going to have better outcomes and stronger patient satisfaction scores. You will have better retention and job satisfaction. Patients, very quickly into their stay, are keen observers of behavior. They can tell when the nurses are happy. You can tell when staff is cared for and secure in what they are able to do.

NR: You do often hear that now is nursing's time because nursing typically measures outcomes. From the science of nursing, we have always been trained to do those things. So as we highlight more patient outcomes in measurements, it actually highlights the impacts nurses have on those outcomes. Plenty of research we've done since early 2000s that will confirm the role of the nurse does impact patient satisfaction scores and outcomes.(3)

Q: What are some things that most often hold nurses back, either from becoming informal leaders among their peers or from taking on formal leadership roles?

CD: When you think about informal leadership, our profession continues to struggle with lateral violence, bullying or "nurses eating their young." It is a known problem, and that kind of behavior could inhibit nurses and make them fearful to step up to the plate.

Formal leadership — such as nurse managers, directors and executive roles — many nurses might feel like it's too much responsibility or too difficult to reach work-life balance. They may have a fear of failure or worry about job security. A lot of times, nurses are promoted into entry level management positions because they were excellent practitioners with years of experience, but they did not receive much development early into the leadership role. Recognize the need for appropriate onboarding and fostering an environment of ongoing leadership development for all nurses.

NR: When you look at the programs or ways nurses are groomed for leadership positions at the charge nurse level, typically they do not get leadership training. What a charge nurse can do varies from one unit to the next, even in same hospital system. There is a lack of clarity around what that particular role means and a lack of consistency about training for it.

Take and multiply it across 4,000+ hospitals across the country. We need some consistency about role definition based on what leadership in a particular role means. A lot of work goes into doing that. Companies like HealthStream and Press Ganey are linking competencies to training. Many companies are trying to do this, and it's positive we're fixing it. [Hospitals] are not really good at paying attention to succession planning — everyone is so busy keeping the wheels on the car. We do need to do a better job at succession planning at all levels so we have leadership tracks in different parts of an organization.

Q: Can you share two or three pieces of advice you'd share with a nurse who is hoping to take on more responsibility or improve his/her leadership style in the next year or two?

CD: Thinking back on my own journey, the first piece of advice is to be open to change. When you think about nursing, it's always changing. That holds true for leadership as well. Embrace possibility. Get out of the silo. Those are critical skills for strong leadership.

Also, stretch assignments. Be open with leadership about your desires. Ask to be involved in a committee. Learn how the organization works and how decisions are made. Network and meet leaders. That's another great way to find out about opportunities. Then, of course, seek opportunities to learn more about leadership. Whatever format works well for you, really learn more about leadership skills and integrate those into your personal practice. That will give you a renewed sense of confidence.

NR: My first piece of advice is to be very clear about why you want to lead or become a leader. Leadership requires you to be flexible. It involves a lot of changes; you just don't know what will come at you. To have resiliency to continue when you fall down or when you need to correct a bad decision that was made, you have to be very clear about why you're doing what you're doing. If you don't know that, you can't be authentic, and people can't follow you because they don't know why you're doing what you're doing. You really need to have a certain type of relationship with yourself and then share that with other people so they understand where you are coming from.

The second thing that confirms what Christy said: Relationships matter. Given all the changes happening, you need to be able to access people at all levels of an organization and all levels of job types. There aren't solo acts in healthcare. Roles and responsibilities, as we speak, are changing. Prepare for changes to implement. If you don't have relationships with people, you can't implement anything. Go to other industries and look at what is going on around you. Speak to and get advice from people outside of your organization. Don't always think about organizations that are the same as yours. You need to be able to step back in a complex world and have opportunities to think differently and make better choices. We sometimes forget to do those things in nursing, which is so detailed and focused. There are new ways to find solutions to problems.

There are thousands of opportunities to learn about leadership, either leadership specific to nursing or as a general construct. A question for anyone isn't so much, "Can I learn?" The question is, "Am I motivated to seek out and learn?" It really becomes a self-development task function at an individual level. If they can't do that, it doesn't matter how we talk about leadership.

Studies referenced by sources

1. Hassmiller, S & Combes J. 2012. "Nurse Leaders in the Boardroom: A Fitting Choice." Journal of Healthcare Management 57:1:8-11. | A 2011 study found that only 6% of hospital board members were nurses.

2. Khoury, C.M., R.Blizzard, L. W.Moore, and S.Hassmiller. “Nursing Leadership from Bedside to Boardroom: A Gallup National Survey of Opinion Leaders.” Journal of Nursing Administration 41 (7/8): 299-305.

3. Wong C.A., Cummings G.G. & Ducharme L. (2013) Journal of Nursing Management 21, 709-724. "The relationship between nursing leadership and patient outcomes: a systematic review update." | A review of nursing leadership and patient outcomes with results suggesting that relationships between positive relational leadership styles and higher patient satisfaction and lower patient mortality, medication errors, restraint use and hospital-acquired infections.

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