Does pondering whether you have a leadership pipeline for the future keep you up at night? Further, as you consider the future of healthcare, are you certain that your current leadership team is equipped with the knowledge, skills, and abilities to navigate the turbulent tides of healthcare reform? At Texas Children's Hospital, we wanted to be armed and ready for the charge. Our journey leveraged a strategic partnership between the nursing and human resources departments. The aim was to transform the existing nurse leadership model to align with our strategic priorities, support the changing healthcare landscape, and position the organization to produce high-quality outcomes. We embarked on a large scale nursing restructure and utilized key competencies in the job creation and interview process, nursing leadership education curriculum, and ongoing performance assessments for the foundation of a robust talent strategy and development of a succession plan.
Background for change
Faced with healthcare reform, national healthcare imperatives, and nursing shortages, today's healthcare landscape is complex.1 To respond to the changing healthcare climate, organizations should conduct a thorough analysis of business practices, processes, department structures, and job responsibilities of both frontline staff and leadership positions. Nursing must strategically position itself to prepare for this uncertain environment within the organization.2
The nursing leadership model at Texas Children's Hospital hadn't changed for several years. A new vision for the nursing department was developed—to be recognized as the nation's leader in both pediatric and obstetrical nursing. A new strategic plan was also developed that focused on exemplary practice, technology, patient and family centeredness, workforce planning, and quality outcomes. To execute the new vision and strategic plan, the nursing leadership structure needed to be reviewed and adapted to support rapid change and produce high-quality outcomes.
Introducing a new model
Key tenants were developed to provide a framework for the redesign of nursing leadership positions:
- Nursing scope of practice statements must guide nursing decisions and hands-on care. Nursing practice should be guided by the latest research and evidence-based practice. Nurses should be leading changes in guidelines, policies, and patient education based on the new knowledge in the literature.
- Structure and process will result in improved patient and family outcomes. There should be a defined structure and streamlined processes to produce positive outcomes. Nursing leadership should be examining both structure and processes within their organizations to ensure the best possible patient outcomes.
- Nursing leaders must be supported clinically and administratively. Nurses should be focused on providing key nursing functions. Other administrative tasks should be performed by support departments or roles. The nurse leader's focus on nursing practice, improvements in care, and nursing quality will ultimately improve overall care for patients and their families.3 The most significant investment a nurse executive can make in an organization and the delivery of quality patient care is the development of current and future nurse leaders.
Defining and implementing nurse leader roles are essential to the delivery of high-quality patient care.4 After developing the key tenants of the nursing redesign, the current nursing leadership structure needed to be changed to support these guiding principles. Two new nursing leadership roles were introduced into the organization: the assistant clinical director (ACD) and the patient care manager (PCM).
The ACD role holds the 24-hour responsibility for one inpatient nursing unit's operations. This role was previously known as the assistant director and typically had responsibility for more than one nursing unit. By decreasing the scope and increasing the accountability for this nurse leader, the ACD is closer to the unit and, ultimately, closer to the point of care. This master's-prepared nurse works closely with nursing staff, the physician partner, key ancillary departments, and patients/families to lead the delivery of patient care. The ACD is a frontline leader who's pivotal to linking the organization's vision and strategic plan with clinical practice at the unit level.
The PCM is a frontline nurse leader on the inpatient nursing unit focused on quality, staffing effectiveness, and family-centered care at the unit level. Reporting directly to the ACD, the PCM supports clinical nurses while still holding a formal leadership role that includes coaching, mentoring, and developing nursing staff. The PCM has a small percentage of time devoted to direct care accountability to maintain clinical competency and this time is primarily spent serving in the charge nurse role.
The Magnet® program challenges nurse leaders to utilize leadership principles to enact transformation within their own practice setting to meet the demands of healthcare in the future. Utilizing a solid vision, influence, clinical knowledge, and expertise in nursing practice will help nurse leaders with this transformation.5
Nursing executives partnered with the human resources department to envision and shape the new leadership roles and conduct a dynamic job analysis. Using a future focus, new job responsibilities were identified that encompassed both clinical and leadership tasks. Based on the new tasks identified, job descriptions were created. Human resources guided nursing leadership through a process to develop business-driven success profiles that aligned with Texas Children's strategic priorities. The activity yielded a set of competencies, personal attributes, knowledge, and experience areas for each role. These competencies served as the foundation of the talent strategy.
The ACD's competencies included:
- emotional intelligence
- driving for results
- facilitating change
- high-impact communication
- business acumen.
The PCM's competencies included:
- promoting patient and family relationships
- aligning performance for success
- building a successful team
- leading through vision and values
- building trust and facilitating change
- making healthcare operations decisions/problem solving.
The ACD competencies build from the core competencies of the PCM role. For example, whereas the PCM is expected to align performance for success of individual clinical nurses, the ACD is responsible for providing influence for a variety of stakeholders who may or may not be in his or her direct reporting structure.
After new competencies were identified, a gap analysis was completed to identify the difference in key responsibilities and competencies that were required in the current state versus what was required in the future role. The gap analysis served as a communication and implementation tool, and helped incumbents differentiate future job expectations from the present. Further, it clearly defined the new roles for the organization and was used to share the vision of leadership impact in detail. The results of the gap analysis showed that the future nurse leader would become more of a clinical expert with a focus on patient outcomes. He or she would also focus on staff support/encouragement and model peer accountability at the bedside.
Selecting top talent
After selecting the key competencies to be used in the screening of candidates, an interview process was developed that included behavioral-based interview questions, which prompted the applicant to give examples of his or her performance in these competencies. The interview process included individual and panel interviews, such as an interview with the nursing director, peer interviews, physician interviews, and clinical nurse panels. Human resources assisted in preparing both the applicants for their interviews and the individuals conducting the interviews. There were résumé and interview simulations offered for the applicants and interview refresher courses for both leaders and physicians conducting the interviews. A tool was created for clinical nurses who participated on the interview panel. This preparatory work ensured a consistent and fair interview process for all applicants.
Throughout the interview process, 14 nurse managers applied for ACD roles and 32 clinical nurses interviewed for PCM roles. A nurse leader oversaw the interview process from a centralized perspective to ensure that interviews were conducted quickly and consistently.
After each nurse leader applicant interviewed, a data integration session was held to identify strengths and opportunities. These sessions were led by human resources and had representatives from each interview panel who shared specific examples from the competencies on which they interviewed. A joint rating for each competency was chosen by the group based on the answers given in all panels. Job fit was also assessed to ensure that potential applicants could excel in the identified competencies and were the right fit within the unit's culture. The assessment of job fit was essential to ensure job satisfaction and long-term retention of the new nurse leaders.6 Along with the rating from each competency and job fit, the group also recorded comments on each applicant's competency, overall strengths, and opportunities.
The results from the data integration sessions were utilized for two specific purposes. First, the data were aggregated to assess the professional development needs for nursing leadership as a whole to identify common strengths and opportunities when creating an ongoing leadership development curriculum. Next, individual data were utilized to identify each future nurse leader's specific development needs. This feedback was given to the nurse leader and the information was also utilized to generate a pipeline of emerging nurse leaders in a comprehensive succession plan.
After interviews and data integration sessions, eight managers were selected for ACD roles and 16 clinical nurses were promoted to PCM positions.
Developing future leaders
The most significant investment an organization can make in the delivery of quality patient care is the development of current and future nurse leaders. Preparing nurses and nurse leaders for success during healthcare reform is a vital component of this investment and reorganization.7 After interviewing and selecting nurse leaders to fill the new roles, a transformational nursing leadership curriculum was designed to support their successful transition.
The first step was to assess the current level of proficiency on the identified competencies for the newly hired ACDs and PCMs across 15 inpatient nursing units. This baseline data served to inform our development strategy.
ACDs and PCMs participated in a 4-hour simulation-based manager ready assessment in which they answered phone calls and e-mails in response to common leadership challenges that they may experience on the job. After completion of the simulation, the nine core leadership competencies assessed were rated by a set of trained assessors to ensuring consistency of the ratings. The new leaders received a detailed summary based solely on the behaviors they demonstrated during the simulation.
The assessment reports were reviewed using a three-step process led by the seven organizational development consultants who supported the effort. In step one, each participant received a 1.5-hour debrief of the assessment in which they learned about their strengths and opportunities, and how those played out on the job. Reviewing the results first with the participant provided him or her with a safe environment to receive the feedback and allowed time to process the results in preparation for the development planning discussion with his or her leader. In step two, the leader of the individual assessed was taken through a 1-hour session to review the results to identify strengths and opportunities from the assessment.
Further discussion included any links to on-the-job observations of behaviors and ideas for areas of focus on the individual development plan (IDP). In the third step, the participant, his or her leader, and a consultant met for 1.5 hours to design a robust IDP.
A 2-year comprehensive training program was developed, which included tools, financial/business acumen, patient- and family-centered care, healthcare reform, leading change, collaboration, shared leadership, coaching/mentoring, and innovation. The first prioritized training focused on quality and included a 9-week Institute for Healthcare Improvement webinar. After each webinar, an experienced nurse executive guided the participants through targeted questions that helped with on-the-job application of the new quality principles.
As part of the new leader curriculum, leaders completed core human resource leadership courses, including courses on creating/executing performance appraisal tools, optimizing performance (human resources policies, coaching, and the progressive counseling process), creating a harassment-free work environment, positive employee relations essentials, and interviewing top talent.
Another component of leadership development included a hands-on manager intensive workshop. During this workshop, the entire nursing leadership team, including the ACDs and PCMs, and nurse educators came together to review unit-level tasks to determine which leader would complete each administrative and clinical task to ensure that the unit functioned successfully with the new roles. The nurse leaders also examined scenarios in which other priorities may arise to determine urgency and a path to resolve the issues utilizing the best available resources within the new nursing leadership model.
In addition to the aforementioned curriculum and manager ready assessment, a playbook was developed for the new nurse leaders that included key information to assist leaders in their new roles. Job descriptions, orientation checklists, and orientation pathways were included, in addition to the nursing restructure design, required competencies, IDPs, leadership articles, and a place to store future articles or notes from leadership courses over the 2-year nurse leadership training program.
Ongoing performance in the identified leadership competencies was assessed during the nurse leader's annual performance appraisal cycle. This constant review and discussion kept the new nurse leader and his or her supervisor focused on the key competencies needed to be successful in the job. For the ACD, the success profiles within the annual performance tool for the first year after the restructure included building a successful team, coaching and developing others, empowerment and delegation, and business acumen. The success profiles identified for the PCM included leadership disposition, building a successful team, delegating responsibility, and facilitating change. All leaders were also able to individualize their performance tools with one to two developmental goals based on their manager ready assessments and interview data integration results.
A pipeline for tomorrow
In order to successfully transform the way your leadership team influences quality outcomes at the bedside, you have to align the leadership competencies you use to select, develop, and promote talent with your organization's strategic priorities. Additionally, developing a pool of talent for today and into the future requires a strong commitment from the nursing department, human resources, finance, and the executive team.
Focused attention on experienced nurses and emerging leaders will ensure an organization's future nursing leadership pipeline. It's essential to identify and utilize key competencies within a nursing leadership structure. The competencies that were implemented in this large-scale nursing restructure were the foundation of our talent strategy. This comprehensive use of nurse leader competencies has provided a solid framework to strengthen the overall nursing department and ultimately ensure a solid succession plan for the future.