When legendary University of California, Los Angeles basketball coach John Wooden passed away recently at the age of 97, he was remembered and praised for caring about the people he led. In his talks on leadership, Coach Wooden said the secret to great leadership is simple: Spend more time listening and learning and you'll be better prepared to lead. In any area of nursing practice, we know that assessment, including listening, is the first step in any successful endeavor.
One of my system's executives recommended The Leadership Challenge by Kouzes and Posner.1 This book provides a simple, yet elegant, framework to describe, support, and prepare for the transition to a new leadership position. Emphasizing that the domain of leaders is the future, the authors define and describe five main practices of exemplary leadership: (1) Model the way, (2) Inspire a shared vision, (3) Challenge the process, (4) Enable others to act, and (5) Encourage the heart.
Recently, the three-hospital system for which I served as the corporate director of nursing education for almost 8 years expanded to include a fourth hospital and was in need of a vice president for nursing. After an extensive interview process involving my current system leadership and the new hospital's leadership team, I was offered the chief nurse executive (CNE) position. In this article, I describe my first 100 days as a new CNE within the framework of Kouzes and Posner's five practices.
Model the way
One of the principal concepts in the authors' framework is that credibility is the foundation of leadership effectiveness. Clarifying your own values and those of the organization and staff is a prerequisite for a valid leadership assessment and establishing credibility with staff and leaders. During my first 3 weeks as CNE, I conducted daily rounds in all nursing areas, with two sets of rounds during the night shift. I set the goal of meeting as many nurses and staff members as possible. I decided against having open central sessions in favor of establishing a presence on the units. In my first month, a snowstorm emergency provided the opportunity for me to stay overnight. Staff members were impressed that I wore scrubs and a lab coat and even offered to help out with simple patient-care tasks.
Within 3 weeks of starting my role, the system CNO held RN staff meetings in which I introduced him and he introduced the staff to the system's nursing philosophy and overall mission, vision, and values of nursing. This initial presentation of the philosophy identified the system's beliefs in holistic patient- and family-centered care based on evidence-based expertise supported by a robust professional development structure. Over 40% of the RN staff from all shifts participated in these meetings. Maximizing transparency, visibility, and credibility with all stakeholders is an important aspect of leadership. After my first month, I sent a thank-you note to each member of the nursing staff, thanking them for their role in helping me during my orientation and assisting me in the initial assessment of nursing. I reinforced my open door policy, but reminded staff members that it may be easier for them to call me on my cell phone than to find me in my office.
Inspire a shared vision
According to Kouzes and Posner, leaders must imagine the possibilities, find a common purpose, and enlist others with passion to implement this shared vision of change. Presenting and discussing the nursing philosophy set the stage for inspiring a shared vision with staff. I repeated the presentation with senior management, physician leaders, and the general medical staff. I listened at least as long as I spoke, knowing that creating a shared vision requires finding a common purpose and understanding the hospital from their perspective. Inspiring this shared vision within the other disciplines and administration will help foster future collaboration.
Continuing the theme of transparency, visibility, and credibility, I took advantage of an opportunity to write an article in our hospital's community relations publication, which reaches our primary marker area, including almost 80% of the nurses who live in the local community. In this article, I validated the well-established presence of nursing at the hospital and described the contributions and value of current staff and managers. This set the stage for integration with the larger system and the upcoming Magnet® journey and explained how nursing would be strengthened by joining the system and eventually pursuing Magnet recognition.
I also took advantage of another major opportunity to inspire a shared vision and to emphasize my concern for, and attention to, patient-care outcomes. Our hospital was presented with the invitation to join a state-wide Transforming Care at the Bedside (TCAB) collaborative, in which a single nurse manager and key staff from that unit were trained, supported, and guided to initiate rapid-cycle performance improvement projects that have a direct care outcome. The TCAB initiative became a focal point for highlighting our shared vision of patient-centered care. The staff quickly achieved success implementing bedside change-of-shift report and hourly rounding, which will be implemented hospital-wide.
Challenge the process
Kouzes and Posner advocate challenging the status quo with purpose, not just for the sake of change, but when the need for improvement is obvious. In my case, I was faced with a track record for the pneumonia vaccine core measure that had never reached higher than 80%. We already had the standing order with an RN screen on admission, but there were process issues that needed to be addressed in the long term. However, in the short term we needed to reach 100%. I advocated with the medical staff for a change in the standing order to administer the vaccine on the day of discharge to the day of admission, meanwhile challenging nurse managers and staff to reach 100% on vaccines immediately.
The challenge to the managers was answered with a heightened level of urgency and pressure to screen all patients over age 65 for the vaccine. Within 1 month, we reached 100%. I didn't use a carrot or a stick, only an appeal to focus on this extremely important patient-care issue immediately and that anything less than 100% was completely unacceptable. Within the next month, I secured the change from the physicians to administer the vaccine on admission, a change that all nurse managers and most of the staff supported.
During my initial daily rounds to visit units and meet staff, I spent time listening to staff and directly assessing other elements of the status quo. During these rounds and discussions with staff, I learned about issues related to documentation systems, physician-nurse relationships, pharmacy support, and nurse staffing. While listening to their concerns, I challenged current methods of patient lifting, admitting a patient, and attitudes and beliefs toward visiting hours.
Enable others to act
As leaders, we need to be challenged in order to develop a cohesive and collaborative team, beginning with a clear projection of trust in the staff, according to Kouzes and Posner. My initial and ongoing goal is to build credibility and trust with all members of the senior executive team, the medical staff, and physician leaders. However, within nursing I needed to engage the frontline nurses to solve professional practice issues in a way that would build trust between leaders and staff.
The Nursing Professional Practice Council had been dismantled several years ago due to a perception that the committee had drifted too far from its intended focus on professional practice to include labor management issues. I recognized that a well-established and effective professional practice council is an important component of any hospital, especially an organization pursuing Magnet® recognition, and that our system's nursing practice culture is based on a solid belief in shared governance. After a careful assessment and collaboration with my two appointed cochairs, I sent a personal letter to selected staff RNs' confirming their nomination and participation in the new Nurse Professional Practice Council.
Unfortunately, I was unable to attend the first meeting due to a previously scheduled vacation, but I didn't want the council to start meeting without a charter and set of directions. So, I videotaped myself with a welcome message that included a clear set of expectations from me. The use of video in this manner helped set the stage for professionalism with a sense of humor as appropriate, and my upbeat and positive message helped set the tone for open communication between and among the members of the council and myself. The use of language is important in building trust and collaboration. I continuously try to use the word "we" instead of "I" when addressing staff and managers regarding direction or need to act. The use of "we" emphasizes the alliance of leadership with staff to accomplish patient care and organizational goals that can only be achieved through collaborative effort.
Encourage the heart
Lastly, Kouzes and Posner note that successful leaders have "high expectations of themselves and of their constituents." In one of my earliest meetings with staff, one of the nurses challenged me with the questions: "Do you mean to tell me you're an optimist? What makes you think things will get better?" Initially startled and somewhat taken aback, I confidently replied with sincerity that I am an optimist and my optimism is based on my faith in nurses, nurse leaders, and the entire hospital team to always do their best for patient care with the proper support and direction.
The authors also encourage leaders to celebrate values and victories, which reinforces the significance of staff contributions to the overall success of the organization. In addition to the community newsletter that celebrated nursing's contribution, I incorporated the mention of our significantly high national certification rate of 38% at every opportunity, such as at Nurses Week events and at meetings of the Medical Executive Committee and the senior management team. This important achievement is a direct reflection of a high level of staff nurse commitment to their profession.
During Nurses Week, I presented a lecture on "Nurse Caring Traditions and Contemporary Challenges" to help create and reinforce the shared spirit of a caring community. I told a story to help reframe the focus on our individual day-to-day tasks that we do for patients to include the larger context that our caring profession represents. In this story, the first bricklayer views his life as a daily grind to lay brick after brick. The second bricklayer believes that the cathedral he's helping to build will be a wonderful monument that his children and their children will see, but probably not in his lifetime. I used this story to caution nurses against getting caught up in their daily grinds of task-oriented duties in which many of us never really get to see the end results of our care.
We've only just begun
As I conclude my first 100 days as CNE, I realize that I'm just beginning one of the most important roles in my professional career with many challenges ahead. Following these five practices helped provide guidance for my initial transition. It's my hope that they'll be helpful to you during your transition to the CNE role as well.