Wolf, Gail PhD, RN; Finlayson, Susan DNP, RN; Hayden, Margaret MSN, RN; Hoolahan, Susan MSN, RN; Mazzoccoli, Andrea PhD, RN
There is common agreement that our healthcare system needs to be transformed; the bigger question is how to accomplish this. Fortunately, we have strong empirical evidence that Magnet®-designated organizations achieve strong patient, staff, and organizational outcomes.1 While many are on the journey, to date less than 10% of the hospitals in this country have achieved Magnet designation, thus depriving many patients and staff of what is possible. Magnet hospitals are required to demonstrate how they have met key principles in transformational leadership, structural empowerment, exemplary professional practice, and new knowledge and innovation.2 However, behind these sources of evidence lies a cultural transformation that must occur for organizations to be successful.
Nelson and Burns3 have developed a framework for transforming organizations. Their High-Performance Programming model illustrates 4 developmental levels: reactive, responsive, proactive, and high performing. These levels can apply to individuals, the organization as a whole, or to a specific work unit. In part 14 of this article, we applied the Nelson and Burns3 framework to the Magnet model® in order to describe what transformation of a unit or department potentially looks like as it proceeds in its journey to Magnet designation. In part 2, we will discuss a 5-step developmental process and leadership strategies for each level of team development.
A 5-Step Developmental Process
A 5-step approach can be used for leaders to assess their departments and develop strategies for moving from 1 developmental level to the next. These 5 steps include (1) assessment of current state, (2) communicating results, (3) empowering staff to create change, (4) strategy development and implementation, and (5) evaluation.3 As departments progress through the developmental levels, the leader needs to continually repeat these steps in order to raise the level of development and ensure a department maintains progress.
Step 1: Assessment of Current State
An assessment of the current state of a unit or department includes both quantitative and qualitative data. Table 1 reports an assessment tool we developed for inpatient units based on the IOM recommendations that care be safe, efficient, effective, patient centered, and timely.5 If the tool is applied to outpatient or ambulatory departments, it would need to be adapted. The quantitative aspects can be compared over time, compared with national benchmarks, or used as an internal comparison. Qualitatively, it is sometimes difficult for a unit manager to accurately identify where a department is developmentally. It is often helpful to have the input of the chief nursing officer (CNO) or director. Accurate assessment is critical as the leadership strategies for improvement are specific to each developmental level. If the assessment is not accurate, the strategies will not be as effective. Once the assessment is complete, the CNO or director also needs to assess for compatibility between leadership style and the development level of the department. For example, a reactive unit requires a strong competent leader who can utilize a directive style, while the leader of a proactive unit needs to be a mentor who is comfortable with staff taking the lead.3
Step 2: Communicating Results
The purpose of this step is to bring the unit to a common level of understanding of its current state. The anticipated outcome is that the team understands its strengths and areas of opportunity. There are many clues in this step as to the developmental level of the staff. For example, a reactive unit often focuses on issues that directly affect it, such as staffing or scheduling, whereas in proactive and high-performing areas the findings typically relate to patients. A reactive unit tends to blame others for their problems, whereas proactive and high-performing units often assume responsibility for the issue and solution.
Step 3: Empowering Staff to Create Change
The purpose of this step is to create a healthy tension between “what is” and “what can be” that motivates staff to change. Staff discussion in this step provides additional insight into the developmental level of the unit. For example, reactive units often feel hopeless and helpless in causing change to occur. Their motivation is “what’s in it for me”? Proactive and high-performing units feel empowered to create their own future and are typically motivated by improvements in patient care.
Developing a shared vision is a very powerful tool6; however, the staff is often unable to visualize the next step of improvement that is possible and may need help in seeing the potential alternatives. Developing a picture of what a unit could become is a critical impetus for progression to occur.
Step 4: Strategy Development and Implementation
The purpose of this step is to create a unit level plan that will take the unit to the next developmental level of their shared vision. As a result, concrete milestones, timeframes, accountability, and outcomes showing improvement are developed. This helps to focus the work of the department and reinforces the belief that staff can create change. It is critical, especially in a reactive unit, that the unit leader monitor progress closely, ensuring that the necessary focus, resources, and expertise are available to achieve the set goals. If the staff thinks they can make change but the plan is not implemented, they become disheartened and unwilling to try again.
Step 5: Evaluation
The purpose of this step is to analyze and evaluate progress toward the unit goals, to identify any barriers to progress, and to celebrate successes. As various goals are accomplished, the 5-step process is repeated, resulting in continual development of the unit.
Leadership Strategies for the Developmental Levels
Evolution From Reactive to Responsive
The assessment of a reactive unit typically reveals quantitative data (such as quality, patient and staff satisfaction scores, turnover, and vacancy rates) at or below the organizational norm. Qualitative data, obtained through staff interviews or focus groups, reveals problems that are staff-centric. For example, nurses will often complain about inadequate staffing levels, other departments, and so on. Often the staff is reluctant to cite any internal problems with their peers for fear of retaliation, even though there is often evidence of bullying or lateral violence. When presented with the findings of the assessment, the staff usually attributes any deficiencies to those other than themselves.
It is difficult to motivate staff to change on a reactive unit unless they can see the personal benefit. One study noted that of all the stakeholders involved in achieving Magnet designation, nurses were the often the biggest barrier citing “what’s in it for me.”7 Unless appropriately managed, action plans will typically be ignored, and the unit will continue to stagnate. Individuals wanting to see change will become frustrated and leave, thus further intensifying the problem.
A reactive work unit is the result of ineffective leadership. It doesn’t necessarily mean the leader is incapable; but rather the strategies being used to lead are not correct. The 2 most common ineffective strategies seen at this level are either a punitive style of leadership or 1 that ineffectively deals with problems due to ignorance or fear.3 The CNO or director should carefully assess whether the manager has the necessary skill set to develop a reactive unit, as this is a high-risk department. For example, if a nurse is too intimidated by his/her peers to raise a question or ask for help, the patients he/she is caring for can be put at significant risk. This type of unit needs a seasoned manager who has strong leadership skills and is not intimidated by strong personalities. In addition, the leader should be able to provide clear direction, set short-term goals, identify responsibilities, and hold people accountable for the outcomes.
Research on which of the 14 Forces of Magnetism (FOMs)8 are important areas for focus in a reactive unit revealed 3 areas with a statistical significance of P = .0001: management style, organizational structure, and relationships.9 The reactive unit is typically run by strong informal leaders who are clinically very competent, but also self-serving and frequently intimidating. Cliques are very typical. Managers need to address these behaviors and help the staff see why a different way is preferable. Strategies such as brainstorming “the perfect coworker” or “the ideal unit” and then developing goals, or unit norms, which move toward that ideal, can be helpful.
Goals for the reactive unit can be derived from focus groups or interviews, but need to be developed and endorsed by the staff. They need to be simple and easily achieved. It is essential that the manager hold people accountable to the agreed-upon behaviors and goals and that progress be monitored and celebrated on a regular basis. As change begins to occur, the staff develop more confidence in their abilities to tackle additional problems. As the disruptive informal leaders either leave or modify their behaviors, the team becomes more cohesive and developed.
Evolution From Responsive to Proactive
A responsive state is so superior to the reactive state that many managers do not move beyond this or realize further development is possible. However, a proactive state is where transformation begins. In a developed responsive unit, the team is cohesive, and the manager is usually well regarded. Goals are typically more complicated but are still concrete and highly achievable. The plan, including milestones, and outcomes are co-owned by the staff and leadership. The leadership and staff together discuss outcomes and develop creative ways to celebrate success.
There are 6 FOMs that are statistically significantly different between a responsive and proactive unit: policies and programs, models of care, quality of care, consultation and resources, autonomy, and interdisciplinary relations.8 A responsive unit is one that “follows the rules”; the evolution to proactive begins to occur as the manager helps to develop the staff’s critical thinking and ability to challenge the status quo, especially in these areas. For example, questions such as “Is this policy based on the latest evidence? How can we improve the way we deliver care? What would it take to get better outcomes than we have been able to achieve thus far? How can we work better with those outside the unit to get where we want to go?” are designed to stretch the thinking and the imagination of the staff. Another good strategy to consider is the power of the peer: inviting a staff member from a proactive or high-performing unit to come and discuss some of their initiatives and how they achieved them. As a result, staff begin to feel more empowered, engaged, and in control of their practice. As the staff develops, the formal leadership, although still essential, becomes less involved in decision making and is utilized more as a resource and coach. Councils are responsible for coming up with specific goals based on their current state. Goals are more complex and typically include areas outside their own department. The plan is more robust, and milestones become increasingly innovative. Recognition often comes from areas outside the department and/or organization. Follow-up is done more informally with the leader as the staff are engaged and hold each other accountable to meet outcomes. The leader’s job is to assist in removing any barriers to successful completion of the plan.
Most Magnet units function at this level, and nurses see the difference that they are able to make. For example, they note that “the organization has evolved to a higher-functioning organization… the bar is higher, practice is better”10 and that nursing is more adaptable to challenges, more innovative, proactive, and able to modify practice and more capable of providing quality.11 In 1 study of 34 Magnet-designated hospitals, nurses confirmed the positive impact of a healthy work environment on patient outcomes and nurse satisfaction, noting the importance of having control over nursing practice, collaboration and influence with physicians, and supportive, visionary leadership.12
The Evolution From Proactive to High Performing
As these efforts and development continue, the staff evolves to a high-performing level. We see evidence of this in redesignated Magnet organizations. Once the assessment indicates the unit is in the high-performing stage, leadership is used mostly as a consultant. At this stage, shared governance is deeply embedded into the fabric of the unit. The staff own their practice, are accountable for their outcomes, and often develop innovative approaches for improving them further. Staff set goals that are challenging and require innovative problem solving. Goals often extend to divisional goals, and staff are utilized as a resource on collaborative, organizational projects. The staff are highly engaged in the unit, the division, and the entire organization and able to mentor other units and organizations. Recognition happens at the divisional/hospital/state and national level as nurses present and publish their accomplishments. A high-performing unit is professionally self-actualized and able to successfully meet the challenges presented to them. One nurse executive commented that “…our nurses expect leadership to partner with them to create meaningful change… this level of shared leadership is supported and sustained by our Magnet environment where accountability by staff at all levels is embedded into our culture.”13
Summary and Conclusions
The Magnet program provides a roadmap to guide us through the complexities facing us in healthcare to achieve Magnet designation; yet, the road is not easy. Organizational leaders must apply transformational skills, engage and empower the staff, and unravel the challenges of teams at different developmental levels. In this 2-part article, the authors share a 4-level model and effective leadership strategies that they have used in a variety of settings to engage and transform their culture to proactive and high-performance levels. Magnet-designated organizations not only include empirical outcomes and evidence that demonstrate exemplary professional practice, but also showcase teams and culture that are leading the way for the future of healthcare.
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