THE DOCTOR of Nursing Practice (DNP) leader is well positioned to impact health care on every level.1 She or he has pursued doctoral education at a university that has invested in a professional degree to support the leadership needs of today and tomorrow. The curriculum for Arizona State University's DNP innovation leadership is an example of this, with a program that includes contemporary leadership theories. Contemporary leadership approaches include complexity leadership and quantum leadership. The role of a contemporary leader is to facilitate change and transformation of processes that are no longer effective.1 These approaches are differentiated from more traditional leadership theories by their focus on intersecting relationships, emergence, and the importance of personal and organizational adaptation to ongoing change.2 Traditional leadership theories operate from a hierarchical, Newtonian approach and are focused on order and stability.1 Quantum leaders with a foundation in complexity science are those who help their followers adapt and thrive in new and emerging health care environments. They facilitate new roles, new processes, and new behaviors.1
Students acquire a deep understanding of this, along with other emerging theories through knowledge acquisition, analysis, and synthesis. The application of this new knowledge is demonstrated in their DNP projects, where students identify problems, issues, or gaps in their organizations. They then develop and execute an intervention and measure the intervention's outcomes through a rigorous search for evidence-based solutions. This process requires an understanding of complex leadership, along with a willingness to transform one's own traditional leadership skills. In short, it requires a resocialization of the individual leader.
Both transformation and emergence of the DNP leader are quite remarkable and become apparent as students and graduates begin to apply new knowledge into real-life situations. The purpose of this article is to present 4 unique clinical/organizational examples that illustrate the applications of complexity and quantum leadership theories in practice changes. The clinical applications include the experiences of DNP-prepared nurses working to introduce evidence-based practice (EBP) in (1) an international medical center setting, (2) an advanced practice role in a community hospital organization, (3) in a student health department within a large university, and (4) as a workforce policy influencer in Colorado. Each vignette illuminates an individual leadership approach and an application of complexity knowledge.
THE EMERGENCE OF A QUANTUM LEADER IN AN INTERNATIONAL PRACTICE SETTING
The transformation to become a quantum leader is a true revolution. It requires patience, curiosity, self-knowledge, and a deep understanding of complexity science and principles. My experience as a DNP student in Yinchuan, China, was the catalyst to drive immense internal self-transformation and emergence.
I had an opportunity to follow up, observe, and coach a young Chinese chief nursing officer (CNO) at Goulong Hospital in Yinchuan, China. I felt well equipped to be a catalyst for this role, having been a Robert Wood Johnson Executive Nurse Fellow and a previous CNO for 2 different hospitals within 2 different large health care systems.
Throughout this opportunity to observe the new CNO in her setting, I became profoundly aware of the significantly complex environment she was working in. There were multiple, convergent changes she would face while leading the nursing workforce in the opening of a new, large hospital. This change would alter current rules of work and called for a nimble, rapid response to a changing environment. She would be reframing work as a journey, focusing on outcomes, and developing an interprofessional team.1 This change would require a cultural shift for the executive leadership, evolving from a strict hierarchical vertical structure to one that would be more horizontally aligned, while allowing for frontline participation. This also required relationship building.1
Recognizing the need to implement EBPs, we began by engaging the nursing leadership from the Goulong Hospital in developing new workflows. These would be interprofessional and would be introduced through simulation and role-play as part of the new hospital orientation. We worked side by side with 2 nurse translators, designated directors, and managers to process flow on the admission and transfer processes for Perioperative, Maternal-Child, Medical-Surgical, and Emergency Room services. A large cohort of physician providers was included and engaged in the process. As a result, the hospital CEO supported the plan to include the new EBP changes in the proposed workflows.
Although the initial focus was to observe, coach, and mentor the new CNO, my role evolved to that of an active leader and collaborator designing new workflows in this Chinese hospital setting. As I have reflected on this transformational opportunity, and my role transition toward quantum leadership, I realize that I was part of operationalizing the complexity principles and/or complexity concepts of emergence and distributed leadership.
Emergence develops when new and unexpected ideas and structures arise from people in a relationship.3 In this example, various groups of independent agents operated to change their current reality to a new way of thinking. Former structures and processes no longer worked for this new hospital setting. As a result, new evidence-based processes were adopted. One example included the utilization of SBAR (Situation, Background, Assessment, and Recommendation) technique.4 Evidence indicates that the use of standardized communication tools and techniques such as SBAR can facilitate interprofessional collaboration and teamwork and improve communication among professional staff.5 I observed the nurses using SBAR taught during the simulation and workflow exercises. Successful demonstration occurred in exchange of information in a patient transfer and during shift report simulations.
Distributed leadership became evident as we began to include the voice of the frontline nurses and practitioners in the design of the workflows. Frontline nurses, selected by their unit managers along with physician champions and ancillary staff, were invited to workflow and simulation design meeting's. They were provided the new opportunity to participate in full-day sessions, which occurred 5 days over a 2-week period. Process flow maps were created and tested with simulation during this time. When simulation was tested, the frontline nurses, as part of a larger, interprofessional team, caught potential redundancies. In one example, nurses noted a duplication of their efforts combined with ancillary efforts, and they were able to reduce admission time for patients by allowing the receptionist to complete most of the demographic patient paperwork. Frontline nurses expressed a great degree of satisfaction, highlighting “Aha” moments at the end of the day with each debriefing session.
Simple systems (defined as the different divisions within the Goulong Hospital) moved together to form more complex systems, as they worked as a larger team within the health care system.6 The rules of engagement for this organization and its various components will continue to change due to the new hospital environment. This will require adaption to operate effectively under new conditions.7 Part of the work with this Chinese hospital was to ensure that the team understands that even after changes in workflows, leadership distribution, and thinking emerge, they must be nurtured and hardwired. A new dynamic platform for leadership will require an openness to never-ending change. Cheng et al8 found that in Chinese nursing practice, strategies and barriers related to EBP resulted from lack of leadership at the organizational level. The study indicated that when top leaders embraced EBP, frontline nurses would be more likely to follow new protocol. I believe the current Goulong Hospital executive leadership team exhibits a transformational and engaging leadership style and have the ability to successfully lead their teams in a complex system.
—Mary McFadden, MSN, DNP Student
IMPROVING PATIENT OUTCOMES THROUGH IMPROVED WORK PROCESSES, AND COMMUNICATION
The principles of complexity guide leaders to move through multiple systems effectively, gain an understanding of how a person and his or her environment are interconnected, and anticipate the impact that results from this interaction. Recognizing complexity allows for a timely response to events and adaptation of actions and behaviors to successfully conduct change.5 I learned more about applying these principles when I moved into a new professional role.
Adapting to a new position as a toxicology nurse practitioner required the application of knowledge gained about complexity leadership, creation of networks to improve communication, and interprofessional collaboration. This role is complex and multifaceted. It requires a multidisciplinary team approach due to the complexity of diagnostic and treatment options in the patient population. While we often talk about the importance of multidisciplinary approaches to safety and positive outcomes for patients, we have not always been successful at these.
One supporting principle of complexity science visibly applies to this clinical situation: systems thrive, based on the intersection of their functions and actions.1 Actions, such as communication breakdowns, diagnostic errors, poor judgment, and inadequate skill, can directly result in harmful consequences, such as patient harm and death.9 This harm can be avoided by effective teamwork, which immediately and positively affects patient safety and outcome.
Creating a dynamic team provides opportunities for multiple disciplines to collaborate in the strategic care of the patients with complex toxicological problems. For example, understanding the importance of a pharmacist and his or her competencies could be additive to our team in our quest to improve patient outcomes, along with the knowledge that these beneficial services are not widely available to patients in our facility, led us to pilot a toxicology rotation with 4 postgraduate year 1 residents and 2 pharmacy residents. We understood that creating a dynamic multidisciplinary team could improve the responsibility and visibility of these members, while providing opportunities to increase their level of practice in the care of the patient with toxicological problems.
Historically, pharmacists were present at multidisciplinary team rounds in the intensive care unit but had never been in the room during the patient examination and evaluation. As a leader, I trusted that a new involvement would lead to leadership development for our new team members in this complex, multifaceted acute care and emergency department environment. Taking the pharmacists to the bedside as the patient evaluation is completed enables them to better understand the physiological changes occurring with ingestions. This leads to development of a more informed treatment plan. In addition, this model of practice is aligned with the American College of Clinical Pharmacy's Acute Care Practice Model, which notes that to facilitate patient-centered care, the pharmacist must take on an active role as a member of the multidisciplinary team.10
My role in this pilot was to encourage each resident to question ideas and take responsibility for high-quality pharmaceutical care of the patient with toxicological problems.4 This was operationalized with daily bedside rounding of each patient on the toxicology service. Each day, residents rounded with either the toxicologist or the nurse practitioner. Then each afternoon, the team met to discuss each patient and his or her treatment plans developed by the resident, including evidence to support their plan of care. Team discussions included sharing one-on-one interactions with patients, and how their empathy was growing and improving in the care of the overdosed patient. Twice a week, a resident was responsible for presenting an assigned topic, supported with evidence-based articles on that topic. In addition, he or she discussed past patients with this specific diagnosis, and how new insights and learning experiences might have modified the past approach to their care. At the end of the rotation, residents were asked to evaluate the program. Residents articulated an increased understanding of the pathophysiology of the toxidromes commonly seen in this patient population. They also verbalized how comfortable they now felt discussing with staff the signs and symptoms that may be observed with certain toxidromes. Verbalizing the importance of that “hands-on” approach with the patient as well as being part of the multidisciplinary team increased their confidence in caring for patient with toxicological problems.
Appreciating the optimal patient experiences they encountered through carrying out the work of delivering effective, evidence-based, individualized drug therapy management, while being a member of a team that improved patient outcomes and satisfaction, was a highlight of this experience.11 Residents acknowledged the importance of effective and viable teamwork as drivers for practice excellence. They recommended to the hospital administration that this rotation be a permanent experience for Pharmacy (PGY) residents.
—Nancy Denke, DNP, 2014
COMPLEXITY THEORY AS A FOUNDATION TO IMPROVE IMMUNIZATION RATES IN COLLEGE STUDENTS
One of the central components of complexity theory is the understanding that an organization is more than a sum of its parts.6 A traditional linear approach could not adequately address the multifaceted interplay among students, health care, and the university systems. Therefore, as a DNP leader, it was essential to provide an innovative solution rooted in complexity theory. This theory provided a foundation for the design and implementation of a new immunization strategy.
In the initial assessment of the immunization effort, linear relationships between multiple departments were mapped. It became clear that linear relationships could not fully explain, nor address, the system in which we worked. Departments interacted with each other and with academic partners in several different ways. Limiting ourselves to linear relationships and top-down structures overlooked the dynamic nature of the university. In providing structure to solve an issue, we had inadvertently removed the energy required for entropic change. Complexity theory defines an approach in which leaders do not seek to control factors. Rather, they understand patterns of connection and look for nodes of interaction in which to facilitate change.
A university is more than a sum of its parts. It is more than academic and student service departments. Health and academic success are not separate goals. They are interwoven throughout the student experience. Students who do not receive their annual flu vaccine are at increased risk for a virus that significantly impacts their ability to attend class.9 Students who contract meningitis can die within 24 for 48 hours or be left with lifelong deficits in cognitive or physical functioning.12 College students are at a particular risk for meningitis B compared with their same-aged peers.11 The knowledge of the intersection between immunization and student success guided a discussion with multiple stakeholders, highlighting the impact a successful vaccination program could have on students.
Another tenet of complexity theory is that simple systems aggregate to form complex systems.6 As a DNP leader, it was essential to see the complexity of the system and recognize the smaller systems within. When our team met, we examined both the larger systems and individual areas that required attention. For example, our institution has a large international population. These students may have a different understanding of vaccines from that of students from the United States. In some cases, students' lack of information leads to lower rates of vaccination. In other students, there is an increased desire to receive vaccines that are not readily available in their home countries. Our health care team worked with the international student office to develop a public health campaign with messages targeted to this specific group of students, which has resulted in an increase in the number of human papilloma virus vaccines administered. In evaluating the intervention for this target population, we recognized that the same campaign could be applied to other populations in the university, creating a system of nodes for action.
A comprehensive immunization strategy is also an example of what Uhl-Bien and Arena2 describe as organizational adaptability. Their model illustrates the adaptive space that holds the tension between the need to innovate and the need to produce. A university health center must have processes in place to streamline immunizations. These include standing orders, nurse clinics, and an incorporation of consistent workflows to ensure that students receive recommendations and access to immunizations.
In addition, innovative strategies, including working with campus, academic, and community partners to provide immunizations outside of the clinic, are essential to moving toward excellence in this area. As a leader, my role is to effectively work in a complex adaptive space, while understanding the tension of both a structured university system and an unstructured innovation mind-set.
This is not a one-time solution. It must be an ongoing approach that requires communication, collaboration, and coordination between multiple entities. The organizational challenges ahead include the allocation of staff, finding places for connection, reducing duplication of services, and embracing a future where new strategies are value-added. The personal challenges include learning to manage these seemingly contradictory forces and continuing to lead others toward innovation and improved practice outcomes in a structured system.
—Rita Wermers, DNP, 2019
NAVIGATING COMPLEX SYSTEMS IN COLORADO TO BUILD AN APRN WORKFORCE
In 2013, as the Affordable Care Act was preparing to launch, Colorado found itself in a challenging situation. There was a shortage of primary health care providers in rural and underserved communities. The state legislature had passed a Medicaid expansion bill, and there was growing concern and awareness that having insurance coverage was only the first step in providing access to care for many communities.
Responding to this growing crisis, the State's Department of Healthcare Policy and Financing requested Colorado's Nursing Workforce Center work to revise the requirements in the advanced practice registered nurse (APRN) laws to allow for more attainable and timely full practice authority.
Colorado's laws allowed APRNs full practice authority only after overcoming a variety of barriers, including 3600 hours in physician oversight and strong opposition by political organizations served by preventing APRNs from providing service to the full scope of practice. The consequences of these barriers contributed to limited provider access for people in rural and underserved areas.
Creating a stronger and more active provider workforce to serve communities in need was an exercise in innovation and complexity, especially when the first step in building a workforce pipeline involved legislation. An innovative approach required the cooperation and collaboration of multiple stakeholders who shared a common desire to provide access to care for all. Achieving cooperation and collaboration presented major challenges. After a year of creating a strategy to lower the barriers to practice, nursing organizations continued to disagree over the process, although their desired outcome was aligned. This created conflict among state nursing organizations, which was recognized and used by the opposition to illustrate the nursing profession's lack of cohesiveness and failure to manage their current authority. Eventually, the legislation passed unanimously because the collective professional nursing community was able to support the legislative change.
The friction created in the process turned out to be a great opportunity for nursing. This is an example of the tension dynamic in action, which sits at the core of complexity leadership. Through the painful process of system change, nursing organizations were able to use the experience to connect and build new relationships. The collegial experience is ongoing as nursing organizations continue to collaborate on legislative initiatives.13
After changing the statute, it was clear that something needed to be done to develop APRNs in communities where providers are most needed. This emerging vision required a new structure and process to be created and sustained to manage the gap between the need for and access to rural providers. The project required recruitment of nurses in rural and underserved communities to agree to continue their education to become APRNs and return to their home community to serve as a provider.
An innovative “Grow your Own” program was developed and implemented. Nurse participants received financial support with stipend money throughout their education. In addition, all agreed to monthly coaching to support program retention and committed to remaining in their community for a minimum of 2 years for every year they received funding.14 The project had an overwhelming response due to the support of multiple statewide nursing organizations. Funding has been provided for up to 145 new APRN students in Colorado. The preliminary outcomes are positive, with 25 APRN graduates currently working in their rural communities. Fifty-six nurses are enrolled in school, and 64 more are scheduled to begin a program in 2019 and 2020.
One unexpected consequence in recruiting local nurses to become APRNs was that they eventually leave their staff nurse position, subsequently contributing to the shortage of staff nurses in community health centers. This created competing priorities between a need for APRN providers and a need for staff nurses.
The future success of building an APRN provider workforce in rural and underserved areas is dependent upon building an RN workforce in those same areas. The next step in this emerging process is to work with middle and high schools to support STEM education and begin encouraging young students to consider nursing as a future profession. Doing so takes funding and strong nurse leadership across the state. There is now hope that the new connections that have developed among state nursing organizations will provide the leadership needed to meet the nursing workforce needs of communities across Colorado going forward.13
—Ingrid Johnson, DNP, 2017
The themes and commonalities, in each example, speak to the need for a different way of viewing health care situations. In each example, the authors have recognized the limitations of linear thinking and have described the emergence and application of their developing complexity leadership.
These emerging leaders have described a practice grounded in complexity science. They have shared the importance of “emergence” in understanding and creating change in complex environments. The authors have identified multiple relationships and interconnections required for the development of new structures and processes. For some, there was an effort to provide adaptive space to merge innovation and change within a traditional structured system.
The creation of a dynamic, diverse team willing to respond and adapt to ongoing change promotes and supports innovation. The authors have demonstrated through positive, measurable outcomes that complexity science provides a foundation for a more useful style of health care leadership.
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