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Original Articles

Building the Profession of the Future

Challenging Assumptions

Weberg, Daniel PhD, MHI, BSN, RN

Author Information
Nursing Administration Quarterly: January/March 2021 - Volume 45 - Issue 1 - p 71-78
doi: 10.1097/NAQ.0000000000000445
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  • Continuing the Conversation

Abstract

THE NURSING PROFESSION is in a critical time for evolution and transformation. Although 2020 was the “Year of the Nurse,”1 the profession's structure, practice, and strength are being tested by an insidious disease, COVID-19. The crisis has illuminated the massive cracks in the health care system that underlie our nursing profession. This is a transformative time for the nursing profession to challenge its assumptions of practice, training, and leadership in order to emerge stronger, better connected, and ready to tackle the future of care delivery.

Crisis breeds innovation when leaders can leverage the chaos to challenge long-held assumptions that are weakened or no longer relevant due to competing demands. COVID-19 has forced organizations to challenge many assumptions such as nursing education, personal protective equipment safety, and workforce supply and demand, among others. In order for nursing to be ready for the next 10 years, nursing leaders need to build a culture that embraces innovation and challenges the past. Fortunately, nurse leaders can use evidence-based innovation and tools to evolve their organizations to high-performing systems ready for the next massive challenge.

A DESIRED FUTURE OF NURSING: INNOVATING BEYOND TENSIONS

Several tensions must be addressed while leaders engage in the necessary work required to develop the future of the profession of nursing (Table 1). Tensions are topics or priorities that have competing interests and create choices or split attention from leaders in order to address.2 Think of tensions as magnets that pull energy of the team toward them that results in a deviation of work from the day-to-day status quo. These tensions have 2 forces, one can pull behavior backward and maintain the status quo and one can be used to challenge assumptions of the way work used to be and catalyze the future of work.

Table 1. - The Tensions Impacting Nursing's Future
Tension Pull Toward Status Quo Catalyst for the Future
Policy restricts access to information instead of supporting it. Clinicians are required to memorize content.
Change activity is slowed because information is shared slowly.
Example: Restricting mobile device access in care delivery areas
Knowledge is organized and accessible in real time. Changes in practice are shared instantly across the profession. Content is accessed and assessed rather than memorized and regurgitated.
Example: Just-in-time learning tied directly to clinician workflows
Training methods do not match practice. Training is often isolated to individual professions. Team-based education includes learners across professions.
Training locations remain predominantly in acute settings only. Training locations include ambulatory, virtual, and home-based tracks.
Physical examination is taught only as touch. Technology is the foundation of learning across the curriculum.
Technology is not incorporated until after education is complete.
Example: Physical examination taught using in-person techniques
Example: Physical examination taught through using in-person, video, telephonic, and digital communication modalities
Location-based work is supported and promoted over flexible work. The nursing workforce is hired into individual locations and restricted from moving as supply and demand change. Through technology, the nursing workforce is able to shift location, type, and focus of care as supply and demand for skills change.
Example: Each hospital has its own isolated, non–supply-and-demand flexible workforce Example: Nurses control own practice and, through technology, clinical expertise and skill matched to needs across the system

These tensions provide an example of how the current policy and structure of organizations have historically restricted the ability for nursing to evolve to the care of the future. By restricting information, not training to meet the needs of the patients of the future, and limiting the ability for the workforce to become more efficient, the profession risks operating in a 20th-century model while the health care system requires a 21st-century mindset.

Building the future of the nursing profession will require nurses at all levels to embrace uncertainty and use the evidence of change science to prepare for a disrupted future. Nursing leaders can challenge the tensions described earlier and create new assumptions about how the profession will evolve. By understanding 3 key concepts, leaders can better frame and anticipate change while leveraging chaos to evolve forward rather than revert. These 3 core change concepts are as follows: (1) crisis breeds innovation; (2) systems self-evolve; and (3) networks overpower structure. Each of these concepts is discussed and linked to the future possibilities of the nursing profession.

CRISIS BREEDS INNOVATION: CHANGES IN THE CULTURE OF WORK

The location, types, and expectations related to nursing work were beginning to change prior to the COVID-19 crisis. Younger generations of nurses are resonating more with location and impact of their work than aligning to one brand or corporation.3 Remote work and telework have been growing at a rapid pace,4 and the supply and demand of nursing work is becoming more flexibly balanced. These trends mimic the move toward a technology-based economy that has been seen in almost every other industry besides health care. Ride sharing, social media, online retail, and the overall sharing economy have shifted the expectations of work and the workforce in most industries—except health care, which staunchly remains locked into economies of the past. The operating assumptions of the past include fee-for-service billing, care being linked to physical locations, and technology viewed disabling care experiences. For many clinicians, technology is a barrier to their vision of how direct care should occur.5 Crisis enables innovation by weakening policies that restricted rapid change, disrupts our normal routines to allow for innovative variation, and creates a focal point to allow networks of people to channel creative energy.6

Reviewing the tensions in Table 1, the COVID-19 crisis catalyzed a shift in each one. Key shifts had to occur. Information is not restricted; it has been unleashed. Social networks, news outlets, and professional associations have opened the floodgates of information as COVID-19 continued to spread. For many leaders who are unprepared for change, this flood of information is stressful as these leaders lose control of the messaging and flow of information that informs their teams' decision making.7 With new information, knowledge workers, such as nurses, are able to adapt quickly to meet the needs of changing situations. For example, as news and social media posts uncover the needs for personal protective equipment in areas treating the highly infectious disease, nurses and industry partners created donation platforms, 3D printed masks, and respirator adaptations and quickly adapted their practice to ensure they maintained safety as they cared for their patients.

Nursing education assumptions were also challenged rapidly by the COVID-19 crisis. As social distancing became the new normal across the country, nursing schools were forced to turn in-person classrooms into virtual training centers, clinical sites were turned into tele-enabled learning opportunities, and graduation requirements were relaxed to support a more dynamic nursing workforce in order to deliver care. Many schools, previously resistant to online nursing education, simply had no other choice but to adapt. The option to go backward was completely removed and adaptation was the only path forward. Now, as we see this form of nursing education take hold, we have the opportunity to explore how we can leverage it for educating the future of our profession. For example, instead of teaching a patient examination using only a stethoscope and person-to-person methods, could we simultaneously teach the same assessment as a video visit, a telephonic visit, and an e-mail or text-based visit? By shifting our education to this new normal, our students will be prepared to practice at any care point in the system, instead of only the status quo, heavily weighted to preparing medical-surgical inpatient nurses. Crisis has shown us a glimpse of our future; primary care will be delivered more through virtual means, and hospitals will be reserved for critical care and emergent surgical procedures; and public health will take on new prominence.8 Leaders need to leverage this crisis to support programs that prepare our students for the future of work. The COVID-19 crisis, already forced the educational system to take the first step, it is up to educational leaders to continue moving forward, rather than reverting to the status quo.

Finally, the nursing workforce was also disrupted by the COVID-19 crisis. Operating rooms shut down, pediatric hospitals experienced lower census, and ambulatory clinics shifted to virtual care. This left the nursing workforce critically unbalanced. As some areas of care were shut down completely and nurses had limited work, in contrast, some hospitals experienced a severe shortage. The status quo of nurses assigned to an individual location creates a severe supply-and-demand issue. During the COVID-19 crisis, nurses were being furloughed in the Midwest, while the East Coast required hundreds of thousands of nurses to meet their growing needs. Nurses had to use platforms such as Trusted Health9 and state-based volunteer platforms to try to self-reallocate because health care organizations were too inflexible to adapt to the shifting demand. In the future, this workforce shift will be enabled by technology and will be much more fluid. As nurses increasingly manage their professional lives online, outside of their place of employment, nurses' ability to understand workforce dynamics and more rapidly shift skills to where they are needed will accelerate.

In crisis, cultural shifts that usually occur over 5 to 7 years suddenly accelerate at light speed, throwing the legacy systems and processes into complete chaos.10 In the case of health care, reimbursement rules were relaxed, physical locations were closed, and technology was one of the only ways to enable social interactions, care delivery, and support for the supply and demand of the workforce. The assumptions that drove most of care delivery in the past were upended, and organizations had to adapt or risk complete failure. Crisis now and in the future does not allow for maintaining the status quo.

The problem is, if leaders do not understand the principles of how change occurs, they will be ill-equipped to respond effectively in times of crisis when an exponential amount of uncertainty, change, and adaptation occurs. To build the profession of the future, nursing leaders need to understand and embrace crisis to catalyze change and rely on the self-adaptation of systems to lead the way, perhaps for the whole industry, not just the profession.5

SELF-ADAPTING NETWORKS: CREATING CONTAINERS INSTEAD OF COMMANDS

Complex system theories describe how large groups of interconnected people and technologies will interact over time and create novel solutions to environmental pressures.6 By understanding how organizations adapt, leaders can be more intentional about their actions to support change activities and focus less on maintaining the status quo. Leaders should think about creating containers that provide constraints, guideposts, and information to teams rather than commanding every action. Leaders who understand that complex systems will adapt even without any formal leadership input will be able to spend less time on commanding the future and instead spend effort to build containers that focus the energy of change forward.6

Like a badly fractured bone, health care has been displaced, fragmented, and become dysfunctional as a result of accelerated change. Yet, despite the chaos, care delivery teams, frontline health care heroes, and nursing practice have adapted while organizations remain slow to react. The work of frontline nurses in response to COVID-19 is a living testament to the ability of networks of people to self-adapt without significant leadership input. For example, nurses were able to invent new forms of personal protective equipment, leverage technology to redirect nurses to the most impacted parts of the country, and develop new protocols to keep themselves and their patients safe. As new information was released, those on the front lines were able to quickly incorporate information, share, and adapt practices in real time.

Self-adaptation is also present outside crisis situations. Nurses on the front line routinely identify novel solutions despite the barriers presented by systems of care. In noncrisis times, these positively focused work-arounds are usually not celebrated. Any deviation from the policy is seen as negative to an organization, even if the deviation is more efficient, safer, and driven by evidence.5 Innovation literature has described these positive deviations as an essential skill set for teams to have as they build toward their desired future. Positive deviance is the practice of thriving in systems that are failing.11

Thriving in systems that are failing is an essential skill of nurses at all levels. As the health care system struggles to work effectively as a whole, nurses are delivering the best care they can, given the situation around them. Leaders can use this concept to more effectively find sources of needed change in their workforce. By actively celebrating nurses who find positive deviations that improve processes, teams can adapt quickly without forcing innovation efforts. These positive deviations are also good examples of how people can adapt professionally. For example, nurses are usually driven by their code of ethics and desire to deliver the best care they can to their patients. Leaders can shift their assumption that work-arounds and adaptations are the result of lazy workers or shortcuts and shift to an assumption that work-arounds are actually the solution to a broken system driven by the desire to deliver the best care possible.5 This subtle shift in framing allows leaders to understand adaptations as a source of innovation and not a challenge to authority.

By understanding the concept of self-adaptation of nurses, nursing units, and organizations, leaders can better prepare for the future. Leaders who see these system changes and new behavior patterns as generative patterns that reflect new ways of work will be well positioned to aid their teams to adapt more quickly. Leaders who remain rigidly married to practices in the past will not be able to adapt and, in many cases, may restrict adaptation all together. These leaders will not function well as the profession evolves and the critical mass of change spreads throughout the network with or without them.

LEVERAGING CONNECTIONS: THE NETWORK IS MORE POWERFUL THAN THE HIERARCHY IN BUILDING THE FUTURE

The ability for leaders and organizations to expand their connections beyond their immediate sphere of influence is essential for leading into the future.7 If leaders remain focused on their own closed networks of individuals and information flow, they will be making decisions without a view of the network. A skill called “Network Engineering” is an essential component in a future leader's toolbelt. Diffusion of Innovation theory helps clarify the need7 for understanding the impact of a network. As change is adopted in a population over time, there becomes a point at which the majority has changed. The change becomes self-sustaining, and it takes more energy to resist the change than to convince others to adopt it. Organizations, policies, and other interventions are less effective in slowing the change once this happens. Even hierarchal control cannot stop the change once this critical mass has been achieved.

Leaders can use network power to their advantage. First, in any population experiencing change, a percentage of people will always be known as “laggards.”7 Laggards are resistant to change even after the change adoption is inevitable. The problem with laggards is that they are usually very vocal and can create distractions for the broader team as it moves throughout the change process. Leaders can use the idea of critical mass and network power to overcome this futile resistance. By focusing on the large percentage of the team that is willing to adopt the change over time, leaders can shift their efforts to celebrate the change, rather than distract their leadership focus toward the laggards who will never change. Trying to convince the inconvincible is not a leadership behavior that will result in a future focus but rather an energy-depleting exercise in futility.12

Second, leaders can use the concept of the network to structure their own day-to-day interactions with the team. For many organizations, the higher leaders rise in the formal hierarchy, the further removed they are from the informal network that influences the work. For example, a director or vice president of nursing usually has very limited contact with the nurses at the front line (information network). Without connection to the informal network, leaders have information that is filtered, skewed, and possibly dissonant from the realities of the organization.5 With incomplete and misinterpreted information, these formal leaders then set policy and practice that may be misaligned with the needs of the patients and the work of the organization. Therefore, by ignoring the network, nurses who are leading into the future are not informed by the best information, which can lead to dysfunctional change efforts.

This concept works in reverse as well. When the front lines are starved of relevant information, truth telling, or access to systems, human nature suggests that people will fill in information gaps with assumptions.7 Rumors fill the information void and everyday decisions are then influenced on information assumptions rather than data and fact. This can lead to conflict and change-related stress that distracts the team from a forward trajectory toward the future and instead circles the team around drama and maintaining the status quo.

Leaders must understand these network dynamics as they can significantly impact how change occurs. Leaders who focus on the formal hierarchy and on controlling the information will form a transactional relationship with the network. Transactional relationships between leaders and the network will result in burnout, misaligned incentives, and even poor patient outcomes.12 Leaders who can balance between the formal hierarchy and the informal network will be able to gain the most insight, create relevant decisions, and support teams as they adapt change over time. Network leaders can also lead more efficiently because they are aware of the distractions of laggards, the misinformed decisions of those not part of the network, and the change adoption curve driving how teams move toward the future. Leading with a network lens is an essential skill in order to move nursing into the future.

PREPARING LEADERS TO LEAD INTO THE FUTURE

Three supporting practices will enable nurse leaders to more effectively lead toward the future (Table 2). By being more intentional about leadership practice and maintaining the same rigor for leadership behaviors as for nursing practices with patients, we can prepare an entire workforce of nurses ready to tackle the future needs of the health care system. First, leaders must train differently; second, leaders need to be held accountable; and, third, leaders must value innovation.

Table 2. - Supporting Future-Focused Leadership
Supporting System Impact Example
Train differently Formalizing leadership training is based on the addition of change science, diffusion of innovation, emotional intelligence, and network-influenced content and behaviors. [Check this carefully!] Promotion is based less on individual interviews and more on exhibited behaviors, understanding of change concepts, and demonstration of network influence. Hospitals formalize leadership succession through objective means and promote based on leadership competency, not clinical excellence.
Accountability Poor leadership behaviors have a significant impact on team and patient outcomes. Leaders are held accountable for poor leadership behaviors as rigorously as we hold teams accountable for medical error. Frequent leadership behavior scorecards support real-time feedback for improving practice.
Value Innovation Leaders follow a rigorous innovation process and expect their teams and organizations to embrace innovation as a tool. Fragmented innovation efforts (such as isolated brainstorming without implementation plans) are removed from organizational behavior patterns. Innovation is an intentional process similar to the rigor given to performance improvement.

To realize a desired future state for our profession, nursing leaders need to train differently. Leadership is a learned skill and is very different from the behaviors needed to be a clinical expert. Therefore, training leaders and building intentionality around how leaders are chosen and promoted are essential for the nursing profession to build a more relevant future. The inclusion of change science and organizational dynamics in all levels of the nursing curriculum is also a key support system that will allow the profession to evolve faster. Without this focus on training leaders, we risk promoting organizations that rely on past practices, anecdotes, and potentially dysfunctional leadership practices as the basis for decision making.

Holding leaders accountable for decisions and actions with the same rigor as we do for medical errors is also essential for building a sustainable nursing future. Evidence suggests that poor leadership behaviors lead to burnout in nursing staff, increased turnover, and even poor patient outcomes.12 Poor leadership behaviors are just as serious as medical errors. Leaders need to be held accountable to practicing leadership based on the evidence of leadership science, and when large deviations occur, formalized processes for remediation and development should be instituted. For example, safety officers would never dismiss a medication error as the result of a nurse's personality. Yet, every day, toxic leadership behaviors are dismissed as personality traits without any investigation. Poor leadership can kill nurses and patients and needs to be dealt with in the same manner.

Leading for the future requires value be placed on innovation as a rigorous change process and not an ad hoc activity, which can catalyze teams to focus on solutions rather than problems. Innovation requires the same effort, rigor, and attention to the process as other structured processes such as performance improvement. Yet, innovation is usually not part of a strategic process. Innovation activities are seen as team-building activities, Post-It note pizza parties, or technology-focused discussion. Leaders who embrace innovation as a way of everyday work, a rigorous process, and a strategic imperative will be successful in leading nursing into the future.

THE FUTURE OF NURSING DEPENDS ON ONE

While leading the future of an entire profession may seem like a massive undertaking, the most important aspect of change is that it starts with one. Leaders can focus on one collaboration, adopting one change, shifting one behavior, or building one new connection. The possibilities for the future of nursing are endless, but the inherent risk is that our profession maintains the status quo. Many structures, politics, and fragmentations in nursing's leadership could keep the profession from achieving its full potential. Unless we focus on the system, the profession as a whole, and the rigorous process of change and innovation, nursing may be left behind as the future of care evolves without us. By training differently, holding leaders accountable for being experts in change, and leveraging the science of innovation, nursing is well positioned to build the health care system of the future, lead it, and completely disrupt the way it has always been done.

REFERENCES

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Keywords:

culture; future of nursing; innovation; technology

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