An Integrated System's Nursing Shared Governance Model: A System Chief Nursing Officer's Synergistic Vehicle for Leading a Complex Health Care System

Seton Nursing reengineered previous models of care and leadership to accommodate rapid growth of its health care system from individual acute care sites to a health care system with consistent quality and standardization of like units across the system. Shared governance promotes collaboration with shared decision making and accountability; however, the role and methods of a system chief nursing officer to connect shared governance across a new system has not been previously described. A system chief nursing officer can significantly influence and guide the nursing strategic direction at all the health care system-related facilities by utilizing a single, systemwide nursing shared governance structure. Using this structure provides a venue to maximize the influence of a transformational leader and creates efficiencies in workforce development, resource management, best practice identification, and spread of initiatives and improvements to adapt to an ever-changing health care landscape. This is the story of one such system chief nursing officer.     

Health policy directions for evidence-based decision making in Canada

The topic, evidence-based decision making, may be seen from many perspectives and levels of policy consideration. Canada has been actively pursuing policy macro-level directions for health information and evidence-based decision making through the National Forum on Health and the Advisory Council on Health Infostructure, together with changes in the federal health ministry, Health Canada, and other important national health organizations such as the Canadian Institute for Health Information. It remains to be determined how these initiatives will fundamentally influence a culture of evidence-based decision making and health information availability and quality for the average Canadian. Canada has, nonetheless, recognized that our health care delivery system has fallen behind in terms of using information management and technology to enable and facilitate the ever-growing information needs of the system. Policy direction provided by the National Forum on Health and the Advisory Council on Health Information offer an agenda for action and strategic direction drawn from two broadly based, highly iterative processes.     

The many roles of families in "family-centered care"--part IV

A parent whose premature twins were cared for at Children's Hospitals and Clinics of Minnesota describes giving back to the hospital as a member of the Hospital's Family Advisory Council. Members of the Council play a range of roles in the hospital. Family Advisory Council members assist the administration in developing, implementing and evaluating the services and the facilities of the hospital system and have input into hospital policies and initiatives. Members also educate hospital leadership, staff, managers, students, and new employees through orientations and in-service training addressing the needs of families and how care can be improved. Family Advisory Council members interact with other patients and families by fielding concerns and suggestions. Children's Hospitals and Clinics of Minnesota have a strong commitment to involving family members as advisors in every aspect of health care and on every level of the hospital system that impacts children and their families.     

The American Organization of Nurse Executives System CNE Task Force: A Work in Progress

Health care is a complex industry, consequently requiring a diverse group of health care executives leading initiatives for efficiency and effectiveness in patient care delivery. Value-based purchasing and pay for performance are at the top of the list for indicators of success, and many hospitals are merging into health care systems. The role of the system chief nurse executive is an evolving role to lead health care systems in clinical, operational, patient safety, and patient satisfaction processes and outcomes. The American Organization of Nurse Executives, being the voice for nursing leadership, convened a group of system chief nurse executives to address the role, function, and competencies needed for this significant and emerging role in health care. This article describes the role statement and system chief nurse executive competencies needed for success in the role. In addition, the next steps for addressing the needs of this group will be outlined in this article.     

The Chief Nursing Officer Shared Leadership Model

We highlight the design, implementation, benefits, and challenges of an innovative shared nursing leadership model at the chief nursing officer (CNO) level. At St. John's Health, a 48-bed rural hospital in the Mountain West, 3 qualified, experienced clinical nursing directors were recruited to fill the CNO position. During the first 6 months, the CNOs solidified their leadership and communication styles, negotiated salary and benefits, transitioned into strategic thinking, became members of the administrative team, and maintained their specialty clinical directorships. St. John's Health retained strong nursing leadership talent and enhanced staff engagement, resulting in better staff wages and work–life balance, and continues to improve patient experience scores.     

The clinical nurse leader: a catalyst for improving quality and patient safety

Aim  The clinical nurse leader (CNL^®) is a new nursing role introduced by the American Association of Colleges of Nursing (AACN). This paper describes its potential impact in practice.
Background  Significant pressures are being placed on health care delivery systems to improve patient care outcomes and lower costs in an environment of diminishing resources.
Method  A naturalistic approach is used to evaluate the impact the CNL has had on outcomes of care. Case studies describe the CNL implementation experiences at three different practice settings within the same geographic region.
Results  Cost savings, including improvement on Centers for Medicare and Medicaid Services (CMS) core measures, are realized quickly in settings where the CNL role has been integrated into the care delivery model.
Conclusions  With the growing calls for improved outcomes and more cost-effective care, the CNL role provides an opportunity for nursing to lead innovation by maximizing health care quality while minimizing costs.
Implications for nursing management  Nursing is in a unique position to address problems that plague the nation's health system. The CNL represents an exciting and promising opportunity for nursing to take a leadership role, in collaboration with multiple practice partners, and implement quality improvement and patient safety initiatives across all health care settings.     

Creating reporting and learning cultures in health-care organizations

Patient safety has emerged as an important issue in Canadian health care, as reflected in the Canadian Council on Health Services Accreditation's patient/client safety goals. Achieving these goals calls for concerted efforts within health-care organizations. To assist nurse leaders in their efforts in developing a culture of safety that is receptive to reporting and learning from adverse events and near misses, the authors explore the challenges and provide four recommendations for action. By enacting these recommendations, nurse leaders can support the analysis and actions necessary to identify improvements that will create safer health-care environments.     

High reliability and implications for nursing leaders

Aim  To review high reliability theory and discuss its implications for the nursing leader.
Background  A high reliability organization (HRO) is considered that which has measurable near perfect performance for quality and safety.
Evaluation  The author has reviewed the literature, discussed research findings that contribute to improving reliability in health care organizations, and makes five recommendations for how nursing leaders can create high reliability organizations.
Key issues  Health care is not a safe industry and unintended patient harm occurs at epidemic levels. Health care can learn from high reliability theory and practice developed in other high-risk industries.
Conclusions  Viewed by HRO standards, unintended patient injury in health care is excessively high and quality is distressingly low. HRO theory and practice can be successfully applied in health care using advanced interdisciplinary teamwork training and deliberate process design techniques.
Implications for nursing management  Nursing has a primary leadership function for ensuring patient safety and achieving high quality in health care organizations. Learning HRO theory and methods for achieving high reliability is a foremost opportunity for nursing leaders.     

Nursing leadership–myth or reality?

The recent profound changes in health care policy and the management and organization of the National Health Service have had a major impact upon nursing. Indeed, the development of the new management culture has challenged the organizational and management structure of nursing. This paper explores the role of nursing leadership in relation to the management of care delivery. The need for nursing leadership, its struggle for emergence and its effectiveness are discussed. The author concludes that for nursing to survive in the reformed health services strong leadership is essential. To achieve this the profession must move away from its traditional power base and refocus on clinical practice and the management of nursing rather than the management of nurses.     

A challenge to meet the future: nursing education in Oregon, 2010

Nursing leadership in Oregon has united behind a plan to address the nursing shortage, setting forth five strategic goals. Two of these are specific to nursing education--to double enrollment by 2004 and redesign nursing education to more directly meet the changing health care needs of Oregonians. This article describes the Oregon Nursing Leadership Council plan and the processes used to develop it. Controversial issues, challenges, and future directions also are discussed.     

Report cards: relevance for nursing and patient care safety

The emergence of health care report cards in the North American environment is outlined. While it is evident that substantial activity has emerged, the majority of these initiatives excluded nursing, or use a broad indicator for nursing that may not provide meaningful representations of the quality of nursing care provided in the system and the relevance of this care to patient care safety. Given that nurses are the primary care provider in health care settings, this represents a significant gap in health care report cards. The pioneering work of the American Nurses Association (ANA) Nursing Report Card in the development and validation of report card indicators for nursing is discussed. Challenges related to data availability and data quality are identified. Potential opportunities for linking nursing practice outcomes to patient care quality and patient safety through a report card process are outlined.     

Developing a preceptorship/mentorship model for home health care nurses

Preceptorship and mentorship programs are used in the health care sector to educate nurses, enhance their leadership skills, and improve their quality of work life. Recognizing the importance of these initiatives, Saint Elizabeth Health Care sought funding to create an innovative model of preceptorship/mentorship that meets the unique needs of home health care nurses. The methods utilized included focus groups, key informant interviews, and a workflow analysis. Factors that influence preceptorship such as nursing workload, preceptor training and remuneration were examined to develop a new model that offers career enhancement and leadership opportunities for preceptors and mentors, and promotes a welcoming environment for preceptees. Reward and recognition programs were created for preceptors to acknowledge their leadership contribution at the front line. This study demonstrates how evidence and innovation were used to create a preceptorship/mentorship model to develop community nursing leaders of the future.     

Engaging and developing research leaders in practice: creating a foundation for a culture of clinical inquiry

This article describes the first formative year experience of a research council in a children's hospital within a Magnet-designated hospital system. The vision, transformational leadership structure, and implementation strategies used during the first year of formation of a Nursing Research and Evidence-Based Practice Council (NREBPC) are delineated and reflect Magnet components and sources of evidence (American Nurses Credentialing Center [ANCC], 2008). The use of the nursing excellence framework (ANCC, 2008) coupled with principles of adult learning to expand the knowledge and skills of nurses on the NREBPC are described and examples provided. Initial outcomes in terms of nurses' leadership for research studies and planned documentation of additional metrics that have the potential to improve care through the development of a culture of inquiry are proposed.     

Forensic Nurse Hospitalist: The Comprehensive Role of the Forensic Nurse in a Hospital Setting

Forensic nursing is an evolving specialty designed to address the unique, intersecting health and legal needs of patients who are victims, suspects, and perpetrators of trauma. The “Forensic Nurse Hospitalist” is proposed as a new term to describe the role of the nurse who is qualified by licensure and education as a specialist in forensic nursing and practices specifically in the hospital setting. The forensic nurse hospitalist can provide comprehensive, medicolegal care to patients receiving treatment for trauma-related injury and questionable death in the acute care setting. The purpose of this paper is to highlight the need and importance of the forensic nurse hospitalist and describe the multifaceted responsibilities of the role as a transformational leader in health care today. It is vital that health care systems employ forensic nurse hospitalists to deliver expert patient care, offer specialized consultation and collaboration, and implement systemwide policy and educational initiatives to best meet the needs of patients who have experienced intentional or unintentional trauma.     

Developing a Preceptorship/Mentorship Model for Home Health Care Nurses

Preceptorship and mentorship programs are used in the health care sector to educate nurses, enhance their leadership skills, and improve their quality of work life. Recognizing the importance of these initiatives, Saint Elizabeth Health Care sought funding to create an innovative model of preceptorship/mentorship that meets the unique needs of home health care nurses. The methods utilized included focus groups, key informant interviews, and a workflow analysis. Factors that influence preceptorship such as nursing workload, preceptor training and remuneration were examined to develop a new model that offers career enhancement and leadership opportunities for preceptors and mentors, and promotes a welcoming environment for preceptees. Reward and recognition programs were created for preceptors to acknowledge their leadership contribution at the front line. This study demonstrates how evidence and innovation were used to create a preceptorship/mentorship model to develop community nursing leaders of the future.     

Scoping practice issues in the Australian mental health nursing workforce

This is the third of four articles on the scoping study of the Australian mental health nursing workforce conducted on behalf of the Australian and New Zealand College of Mental Health Nurses (ANZCMHN) for the Australian Health Ministers Advisory Council (AHMAC) National Working Group on Mental Health (NWGMH). Its purpose is to focus on factors that significantly affect mental health nursing practice. The issues of advanced practice, regulation of nursing, accreditation, credentialling and demarcation with other disciplines are addressed.     

"Towering genius disdains a beaten path" Abraham Lincoln

We see nursing leadership existing at all levels in nursing...all nurses leading. Nurse executives within academic health environments across Canada will be influencing health policy directions and dialogue within the profession nationally. They will be contributing to the development of a national agenda for nursing practice, education, research and leadership. These nurse executives will lead in a way that makes an invigorating impact on human service in health care environments and they will be dedicated to preparing the nursing leaders of tomorrow. The Academy of Canadian Executive Nurses will connect with the Office of Nursing Policy, Canadian Nurses Association, Canadian Association of University Schools of Nursing, Association of Canadian Academic Health Care Organizations and others to develop position papers regarding key issues such as patient safety, health human resource planning and leadership in the Canadian health care system. Our definition of professional nursing practice, fully integrated with education and research, will be advanced through these endeavours. The end result of a strong individual and collective voice will be improved patient outcomes supported by professional nursing practice in positive practice environments. This paper is intended to stimulate dialogue among nursing leaders in Canada, dislodge us from a long and traditional path, and place us firmly in a new millennium of leadership for the profession and practice of nursing, a style of leadership that is needed, wanted and supported by nurses and the clients we serve. It is the responsibility of those of us who lead in academic health science centres to be courageous for the students we support, the puactitioners we lead and the renewal of the profession. We are the testing ground for nursing research, and need to be the source of innovation for nursing practice. It is incumbent on us to leap forward to engage a new vision of the professional practice of nursing with a reconfigured work design and work environment compatible with the new economy, workplace and workforce.     

Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice

High-reliability health care organizations are those that provide care that is safe and one that minimizes errors while achieving exceptional performance in quality and safety. This article presents major concepts and characteristics of a patient safety culture and a high-reliability health care organization and explains how building a culture of evidence-based practice can assist organizations in achieving high reliability. The ARCC (Advancing Research and Clinical practice through close Collaboration) model for systemwide implementation and sustainability of evidence-based practice is highlighted as a key strategy in achieving high reliability in health care organizations.     

Improving the culture of patient safety through the Magnet® journey

This article outlines how one academic medical center's nursing service has developed programs to improve patient safety and quality outcomes through the use of the Magnet Re-Designation Accreditation Process(R) and a shared governance model. Successful programs have been implemented across the continuum of care. These programs include educational initiatives that increased both the number of nurses with BSN degrees and specialty certifications and also the number of patient-focused initiatives, such as a reduction in central line infection rates, an increase in hand-washing compliance, and a decrease in fall rates. In this article we will describe how our Magnet Re-Designation Accreditation Process(R) and shared governance model have contributed to strengthening our culture of patient safety. The manner in which the Magnet components of transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovation and improvement; and empirical quality results have all contributed to improved patient safety are discussed.     

Maine's nursing workforce legislation: lessons from a rural state

As the aging baby boom generation begins to place additional pressures on the health care system and the nursing workforce of the same generation begins to retire, the worsening nursing shortage has the potential to seriously impact the delivery of health care in the United States and is receiving considerable attention nationwide. Although federal initiatives such as the Nurse Reinvestment Act are critical, issues of supply and demand for registered nurses must also be addressed at the state level. In Maine, nursing leadership has partnered with state policy makers and health care industry leaders in a multi-year initiative that has included the nursing community's envisioning its "preferred future," formal data collection on the nursing workforce, ongoing education of the Maine State Legislature about the nursing shortage, and legislative initiatives.