Breaking the Glass Ceiling for Nurses in Health Care Organizations
From 2005 to 2008, the National Center for Healthcare Leadership conducted research to identify best practices for increasing the role of nurses in the senior leadership of health care organizations and designed a model intervention for enhancing nursing leadership.
Project staff developed a model intervention including executive coaching and problem-solving through teamwork, but were unable to pilot test the intervention during the grant period.
Six core factors that appeared to enhance organizational effectiveness in quality and safety initiatives were:
- Clarity of focus on quality and safety priorities and clarity of roles regarding quality and safety initiatives at all levels
- Competencies of the chief nursing officer as an individual and in his/her relationships with key people: chief executive officer, chief financial officer, service line directors and nursing staff
- Teamwork and collaboration among the senior leadership team in establishing quality and patient safety goals
- Employee engagement including sufficient access to the chief nurse officer and chief executive officer and input into and support of policies
- Adequate resources to pursue quality and patient safety objectives
- Accountability and the alignment of incentives with patient care priorities on the unit
The Robert Wood Johnson Foundation (RWJF) awarded $380,000 to the National Center for Healthcare Leadership for the project.
The Institute of Medicine's 2000 report To Err Is Human: Building a Safer Health System described gaps in patient safety in our nation's health care system. In its report, the IOM identified both management knowledge and skills and the development of effective health care organization leadership teams as necessary to achieving its recommended improvements in health care quality and safety.
In November 2001, RWJF helped support the establishment of the National Center for Healthcare Leadership along with the W.K. Kellogg Foundation and other funders with four grants totaling $1,028,583 (see Grant Results on ID# 049126, etc.). The center's goal is to improve health system performance and the health status of Americans through effective health care management leadership.
The impetus for this project was the center's recognition that the role of the chief nursing officer in senior leadership teams is pivotal to the achievement of improved quality and safety outcomes in patient care. Yet according to Marie E. Sinioris, M.P.H., president and chief executive officer of the center and project director, the role of nurse leaders may have been undervalued and/or underutilized.
"By and large, there is a marginalization of nurses; they're not an effective voice at the table given the scope of responsibilities and knowledge that they have," according to Sinioris.
The RWJF nursing team (a part of the Building Human Capital team) is seeking to improve the culture and work environment for nurses in hospital settings. Chief nursing officers face many challenges in performing their roles, which may partly account for the high turnover in these positions. Interventions aimed at improving the functioning of senior leadership teams in health care organizations may create a more favorable climate to transform care at the bedside and improve nurse retention.
RWJF has invested over $150 million in nursing programs over the past 30 years, supporting programs that help to build the profession, improve the quality of patient care, and address an ongoing shortage of nurses. One ongoing program for nursing leaders is the Robert Wood Johnson Foundation Executive Nurse Fellows program. See Grant Results for more information.
From 2005 to 2008, the National Center for Healthcare Leadership carried out this project designed to assess and identify opportunities for strengthening the role of the nurse executive in healthcare leadership teams.
The project team at the center conducted two types of research to assess barriers to effective management teamwork and use of nurse leaders to optimize such teamwork and to gain insight as to possible interventions to overcome these barriers:
- On-site interviews in eight hospitals with a cross section of individuals regarding the role of the chief nursing officer within the senior leadership team in improving health care quality and safety.
- Leadership assessments via online surveys in six of those hospitals with the executive team, chief nursing officer and nurse leaders through three service lines (medicine, surgical and cardiovascular).
Interviews on Role of Chief Nursing Officers
Project researchers conducted two-day, on-site interviews about quality and safety practices and nursing leadership competencies with executives, board members, physicians, nurse leaders and nursing staff at each of eight hospitals, representing four health systems operating in five states (California, Iowa, Michigan, New York and Texas).
All hospitals were part of the center's LENS network, a collaborative learning network that shares best practices in leadership and management. Six of the hospitals had also received Magnet status from the American Nurses Credentialing Center, a program that recognizes health care organizations providing nursing excellence. The project director noted that these hospitals were not randomly selected.
The researchers interviewed approximately 20 to 25 people at each site.
After completing the on-site interviews, project staff identified a need for additional research to design a leadership development intervention. So project researchers completed leadership assessments at six of the sites with the executive teams, chief nursing officers and nurse leaders.
The center developed an online assessment protocol that included various surveys, such as the center's Leadership Competency Assessment and the HayGroup's Organizational Climate Survey.
These models identified desirable skills and competencies for health care executives. The Leadership Competency Assessment, for example, developed definitions based on over 31,000 behaviors of health care leadership gathered from national research to identify specific behaviors that are essential to quality, patient safety and team effectiveness. The HayGroup's survey asks managers and their teams to assess how their working environment is versus how they would like it to be.
Total participation in these assessments included over 400 health care leaders, their management team members and other employees from six of the eight hospitals. (Project staff members were unable to schedule the additional research at two of the sites.)
Project staff also asked the chief executive officers at each of the six sites to complete a survey on their organization's leadership development structures and processes, including governance and human resource strategies.
Project staff prepared an organizational summary that they shared with the chief nursing officers and the senior leadership team at each organization.
- Based on the results of the research, the National Center for Healthcare Leadership designed a leadership development intervention including:
- Executive behavioral coaching, in which center-certified coaches use anonymous feedback from an executive's colleagues to help guide the executive in addressing performance issues and becoming more effective.
- Team action learning, in which a leadership team is brought together to tackle a real organizational problem, facilitated by a coach who encourages learning and networking through activities such as small group discussions and journaling.
- Job rotation, for example, assigning a nurse charged with developing the business case for quality and patient safety initiatives to work with a chief financial officer to learn about cost analysis.
Under the original proposal, this model intervention was to be piloted at three sites. Project staff did not carry out the pilot test during the grant period because of unanticipated time and cost constraints, including the need to conduct the additional research and the difficulties in engaging executive teams in health care organizations and finding time in their schedules for such an activity.
The center presented project findings in a final project report to RWJF:
- Analysis of the site interviews identified six core factors that appeared to enhance organizational effectiveness in quality and safety initiatives:
- Clarity of focus on quality and safety priorities and clarity of roles regarding quality and safety initiatives at all levels.
- Competencies of the chief nursing officer as an individual and in his/her relationships with key people: chief executive officer, chief financial officer, service line directors and nursing staff.
- Teamwork and collaboration among the senior leadership team in establishing quality and patient safety goals.
- Employee engagement including sufficient access to chief nurse officer and chief executive officer and input into and support of policies.
- Adequate resources to pursue quality and patient safety objectives.
- Accountability and the alignment of incentives with patient care priorities on the unit.
- The leadership assessments revealed that despite the eight hospitals being generally better than average performers, some if not all of the core factors were lacking in most. For example, the lack of organizational alignment, difficulty in setting organizational priorities around quality and patient safety initiatives, physician involvement—or lack thereof—were barriers often noted, as was uneven staff engagement.
- Deficiencies in partnerships and communication among nurse leaders and physician leaders were found at most hospitals. Few hospitals engaged in interdisciplinary team development at any level.
- Many administrative and physician leaders did not understand the role of nurse leaders in promoting quality and safety. Frequently, floor-nursing management personnel did not have clear input into how management processes were working.
- In several cases, personnel with front-line accountability for managing quality and safety processes felt overwhelmed, in some cases "bombarded," with quality and safety procedures that sometimes felt irrelevant to what they were doing. Nurses' voices were not being heard at the direct care level nor translated up to the executive suite.
Project staff noted four key factors that appeared to affect the successful, team-based implementation of quality and safety initiatives:
- The essential role of front-line caregivers in the entire quality and safety process. Quality and patient safety initiatives will not be successful without active employee engagement.
- Continual efforts to optimize senior leadership team effectiveness in achieving quality and patient safety objectives. As the external environment changes and new skills and competencies are needed, even already successful teams will need guidance.
- Involvement of board members in the active support of quality and safety goals and in keeping the initiatives on track.
- Leadership's understanding and acknowledgement of the stress and extra work that frontline staff experience as they engage in quality initiatives.
AFTER THE GRANT
The center received a planning grant from Blue Cross/Blue Shield of Massachusetts to conduct focus groups and on-site interviews in that state, to continue to refine the leadership development intervention.
GRANT DETAILS & CONTACT INFORMATION
Increasing the role of nursing in senior leadership of health care organizations
National Center for Healthcare Leadership (Chicago, IL)
Dates: December 2005 to June 2008
Marie E. Sinioris, M.P.H.
Report prepared by: Gina Shaw
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Rosemary Gibson