As the turmoil of healthcare reform continues to capture the nation's attention, revolutionary changes are underway in our healthcare system. Most important to patient care is the shift of service delivery from the hospital setting to the community and home. Nurse administrators face many challenges in this new environment. The integration of healthcare agencies requires nursing practice to cross multiple settings, increasing the autonomy of the professional nurse.
With increased autonomy, comes the challenge of a new process for supervision and new arenas of supervision that include coworkers and ancillary staff. Each practicing nurse must assume responsibility for independent and interdependent practice within the framework of a managed-care, interdisciplinary team. Nurse administrators will need to guide the leadership development of staff members in the transition from the hospital structure to community- and home-based settings. This article predicts how the authors see the Manager as Developer Model (MADM)1 used in this transition.
Community Health Centers
It has been said that “Once you have seen one community health center, you have seen ONE community health center.” This statement reflects the diversity inherent in the community health center movement in our country. The first community health centers were established in Boston, Massachusetts and Mount Bayou, Mississippi in the mid 1960s.2 Drs. Jack Geiger and Count Gibson had a vision of healthcare that would be responsive to a community's needs, both in the type of services delivered and the manner in which these services were delivered. Since the 1960s, more than 600 centers have been established throughout the country. Although vastly different in the detail of their operations, all share the common base of being community developed and community controlled.
Current health centers provide a wide range of services. Healthcare financing has steered the majority of services to a secondary intervention model of screening and treatment of common illness coupled with primary care services. However, health centers have managed to retain, and even expand, a range of service outside of the traditional healthcare model, with programs addressing social health concerns such as education, violence, and housing.
After two decades of shrinking resources, health centers are embarking on the hope, if not reality, of renewed funding. With additional funding, the services of centers and home care can be expanded and the focus of primary, community-based services reinforced. Nursing is the logical health profession to frame these services, in collaboration with the community and other health professions; however, nursing does not have a strong presence in health centers, nor does the discipline have a strong voice in the policy-making forming the structure for financial support.
In a recent study conducted by Hackbarth and colleagues,3 the researchers found 30% of community and migrant health centers did not have a nurse employed and the national average number of nurses in health centers was 2.7. Fifteen percent of the nurses working in health centers were licensed practical nurses. The scope of practice for the health center nurses concentrated on skilled tasks, not the broader conceptual, educational role of professional nursing.
To increase the presence of nursing in community health centers, two events must occur: 1) the ability to recruit and retain nurses in a setting in which the role is unclear and 2) the preparation of a new generation of nurses educated to provide the services of primary, preventive community-based care and home care. The concept of a teaching health center that is unfolding in the health center movement is very similar to the teaching nursing home developed by nursing. Opportunities to develop an educational environment are rich, yet the leadership of nursing role models first must be developed in this setting. In a comparative study of nurse leaders in both hospitals and community health agencies, Dienemann and Shaffer4 determined that managerial responsibilities have decentralized to first-line managers, especially in the areas of human resource management. The Manager as Developer Model (MADM) is used successfully in both acute care settings and education. It also can be used in preparing leaders in community-based care.
Application of the Manager as Developer Model in Community-Based Settings
The MADM has seven major concepts as the basis for the development of professionals. These are tangential vision, or the ability to set common goals among a group in an organization; staff development, the recognition of strengths and limitations in individual practitioners and the skill to stimulate growth in these areas; team development, the matching of talents of individuals who make up a group and work toward common goals; group decision making, empowering a group to make decision and to accept responsibility for these decisions; staff autonomy, respect for individual practice and the professional need to retain a defined scope of responsibility; two-way communication, listening to what is said and what you say in an effort to understand the views of others; and finally, external influence, a recognition of the importance to explore the outside environment and be alert to and influence events outside of the designated unit.
This process-oriented framework, based on the MADM (Fig. 1), consists of a series of workshops that allow a concept such as vision to be conceptually taught along with a series of skill-building learning activities that enable learners to communicate inspirationally their vision for where their organization is going. This includes observation of vision statements, practicing both writing and articulating them while mastering how to convey this to staff members. According to Nanus,5 such an approach to developing tangential vision is systematic. It starts with understanding the current status of the organization, then proceeds to drawing the boundaries for the vision, positioning the organization in its future external environment, and finally, to defining and packaging the new vision.
In healthcare, a shift in emphasis is occurring in the preparation and functioning of nurses in primary healthcare for solo, group, and interdisciplinary practices. The environments are becoming more community based and community focused. Nursing centers for delivering healthcare are evolving, and a call for both a redirection of emphasis in nursing education and nursing research on health promotion and disease prevention at the aggregate and community levels has been mandated.6 Leaders with a strong ability to think conceptually are vital to setting the direction because the ability to think strategically involves comprehending the current and future environment.7
Can the MADM improve the conceptualization of the leader's role in community-based nursing? Because some of this ability comes from education, native intelligence, and experience in healthcare, this ability would be enhanced through formal education by exposing potential nurse leaders to classes and workshops that encourage conceptual thinking about issues facing healthcare. An example follows. The trends indicate that nurse administrators in community settings—as those in hospital settings—must be taught to manage their own budgets and be prepared to communicate in a common language with the chief financial officers of their institutions. They must be guided in evaluating their own unit/department/institution in terms of cost-effectiveness and defend proposals that are costly but necessary for improving the quality of care. This information then must be transmitted to staff members, who are partners in this process of making it happen. External influence, tangential vision, and two-way communication are just a few of the concepts to be learned in an experiential mode.
Conger7 sees another aspect to conceptualization. He supports conceptualizing the leadership role itself to know “how to be” and “act like” a leader to understand its distinctiveness from a managerial role. It is learned on the job by observing successful and unsuccessful managers in a variety of healthcare settings. Training does formalize the process by exposing administrators to a rich range of examples of leaders in specific healthcare institutions by providing simple models to distinguish between concepts. An application of MADM is demonstrated in this example. A staff member who was familiar with MADM relates witnessing her nursing manager negotiating with the vice president of financing to obtain money to purchase additional small equipment for the clinic, not represented in the operational budget. The core of her proposal was a reallocation of funds from capital improvement savings that were not needed. Although she was informed the savings had been reallocated to another area of the clinic, her request was granted because of her persuasive presentation, which displayed her influence. Learning MADM demonstrated “how to be” and “act like” a leader. The staff member in this situation was aware of the full scope of leadership.
For community-based nurses, a critical consideration in developing leaders is the ability to capitalize on individual self-awareness, personal needs, interests, and self-esteem. Realistically, each of these components are linked to a leader's motivation, yet providing education and training that help clarify and develop the individual's interests may help them to assess their suitability for this particular area of leadership in nursing. Community health centers are unlikely to have more than one or two nurse administrators in the organization. The nurse leader will be making decisions without the support network of peer consultation. Such a leader must be comfortable in risk taking and possess the ability to appear credible to others. In MADM workshops, nurse leaders practice assertive skills and engage in confidence-building exercises that build self-esteem.
In addition to the workshops experience in the MADM education is a combination of self- and staff assessment of the participant. Participants assess their own leadership style while their staffs review the participant's style, based on the MADM framework. Questionnaires are mailed to workshop faculty members, maintaining confidentiality, and feedback is provided by the faculty in an aggregate method, avoiding identification of the respondent. Information is collected shortly after the beginning of the series of workshops and again shortly after the final session. Feedback sessions, conducted on a one-to-one basis during the workshops and again after the final session when the participant is practicing in the workplace, stimulate personal growth by heightening the participant's awareness of needs and behavior that get in the way of leading while setting realistic goals to develop their leadership qualities further.
Several studies, both completed8,9 and in process (Aroian J, Gilbert J, Meservey PM, unpublished data, 1995), have applied the MADM to nurse managers in acute care settings and students in a nursing administration program. Results support the effectiveness of the model to improve the leadership skills of participants. Further, findings of the studies support the need to identify and develop the untapped human resources of staff nurses. Students participating in the model application also observe and report on the leadership behaviors of their preceptors in the clinical practicum. Analysis of these observations reinforce the concepts of the model and the aspects of “how to be” and “act like” a leader.
Implications for Nursing Administration
Several contemporary leadership programs approach developing leadership from the four domains of personal growth experiences, conceptual development, feedback, and skill building. Our approach suggests using the MADM to actualize this process oriented approach. Research to date8,9 supports the reality that we are only beginning to understand some of the potential tools that education can offer us in the development of leaders. As suggested by Conger,7 “The art of leadership development is very much in its infancy.” Organizations must share the principal responsibility for nurturing leaders. Organizations feel more secure with managers. Given the impact of current and future scrutiny of healthcare delivery, this attitude will have to disappear.
Clifford10 counters that what was of great significance in the successful development of Boston's Beth Israel Hospital's Professional Practice Model was the development of the unit-based leadership role. Nurse managers needed to learn how to disengage from the specifics of patient care management and yet still involve themselves freely in patient care activities to assist primary nurses to develop as professionals. A consistent part of clinical management practice must be how to place accountability for patient care on staff members and how to hold them accountable for this care. This expectation of the nurse manager requires a management style that is open and honest in its communication, nonjudgmental and yet comfortable in expressing ideas, and quick to praise and compliment others. A willingness to continue their own learning is essential for nurse managers to continue to value the learning and developmental needs of clinical staff members. Nurse managers at the Beth Israel take their dual role as hospital manager and clinical leader very seriously. They are as intent in managing their own cost center resources as they are in putting the educational needs of patients and staff as a top priority and serving as mentors for clinical nursing staff members. We are just beginning to uncover the knowledge embedded in clinical nurse management practice supported by research.11
Such a model of clinical leadership is readily adaptable to the community health center. Key considerations in the adaptation are the supports for growth of the nurse administrators and the development of a strong interdisciplinary team that includes community representation. Support can come from the connection of nurse leaders across centers through the facilitation of local nursing administration education program, clinical nurse leaders in acute care, community health center associations, and other professional organizations. There must be an opportunity for discussions of innovations, challenges, and risk taking to occur with the validation and contribution of a peer group.
With a small work group, as is commonly the situation in a health center, the concept of the manager as developer must extend beyond nursing to the full interdisciplinary team, encompassing support personnel such as outreach workers and health educators. This will be new territory for nurse administrators, but a role that is developing in many clinical settings. The sharing of trials and tribulations again will provide guidance for the nurse leadership to follow.
A challenge awaits us in community-based healthcare. A broad vision is called for that powerfully drives nursing to take the leadership in community-based healthcare and move it toward excellence and long-range success. Nursing must see this goal as attractive, worth-while, achievable, and widely shared as part of our work in our discipline and vital to meet society's healthcare need currently and in the future.5 This is why it is necessary to prepare nurses for leadership role in policy-making and in the design, development, management, monitoring, and evaluation of population-focused healthcare systems. Emphasis on the strategies to support nurses in these roles is essential.
Leadership development is a complicated and time-consuming process. It requires a serious commitment in terms of time and human resources. There appears to be no quick fixes or magic solutions; rather, it is a never-ending process that demands continual experimentation and dogged persistence. What greater opportunity to exercise this than in our present healthcare system, with its quest for quality, cost containment, and community-based delivery of services, and what better discipline than nursing to develop the leadership for it using the Manager as Developer Model?
The authors thank the nurse managers and their staffs who participated in the early studies, the nursing administration students at Northeastern University College of Nursing, their staffs, and preceptors who are participating in this ongoing work on nursing leaders. The authors also thank the Northeastern University College of Nursing faculty and administrators for their support of these curriculum and funded research endeavors.
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