Practice: What Is the Greatest Challenge Currently Facing Leaders in Nursing Practice?
"The corporate goal of efficiency took precedence over patient well-being, interdisciplinary team cohesion and nurse satisfaction. Time for quality nursing care became a prized and contested commodity." This quote, from a recent study conducted by Rodney and colleagues (2002) in British Columbia, struck me like a ton of bricks when I read it. The study explored the "enactment of the ethical practice" of the staff nurse and described the angst and the moral struggles that nurses face as they attempt to keep their commitments to the client and their passion for their profession.
It's not that the sentiments were a surprise. I see these struggles in my work with staff nurses as they work hard to keep their anxieties from their vulnerable clients. They worry about being forced to increase the client-to-nurse ratio, about lack of support staff and about the persistent feeling that their perspectives are neither sought nor valued.
For me, it seems as though we are still having the same discussion after all these years. It's the seemingly never-ending cycle of trying to foster and protect the values and principles of nursing in the corporate world's vision of healthcare. It's that nurses are often treated as commodities and their numbers increased or decreased according to the latest corporate trends rather than according to current available data about outcomes for clients or about impact on recruitment or retention.
As I see it, the challenge is to continue to strengthen our profession so that nurses can keep their commitments to clients and be proud of their profession and their role in it. If we are unable to achieve this goal we will not be able to recruit into the profession. Neither will we be able to retain nurses at the bedside or in management, for the days of disillusionment will far outweigh the days of honour in calling oneself a nurse.
In my practice, I see that if nursing relationships are strong, nurses are strong. If relationships are weak, then the teams become divided, the messages delivered are not heard and the quality of care suffers. Investing time and energy in supporting strategic relationships is energy well spent for nursing leaders.
I am not discouraged. Despite the days when one wonders if we have made much progress beyond the paternalistic Dark Ages, I see slow and steady progress toward an ever more politically and intellectually powerful nursing presence. Over the course of the last budget-crunching exercises in our organization, I came to the realization that we have the power to succeed if we can harness our collective energies. Through the use of strategic relationships in nursing, I witnessed a level of collaboration across units, across divisions and across our multi-site organization that has forced a different level of deliberation.
With a common understanding that the bottom line had to be the preservation of the nurse-to-client ratio, nurse managers and directors began a campaign of careful articulation of evidence about client outcomes, cost to the system in closing beds and current clinical endeavours to increase client satisfaction. They used local, provincial and interprovincial networks to survey like units across several provinces. Directors kept managers apprised of the pressures and the politics of the budget process, and managers and directors worked closely with their medical counterparts to ensure that there would be partnerships in the argumentation.
As I write this, it all seems so flawless and so easy. It was not, and is not. Building and fostering strategic relationships requires energy and commitment, but it can also be a reward in itself. As my colleagues discovered, being connected to one another as managers and directors allowed them to anticipate and negotiate with more confidence, decreasing feelings of powerlessness. Using alliances and peer feedback allows even promotes creative problem-solving.
At the unit level, discussion with staff nurses has helped to decrease fears about job loss and increase awareness of the place of nursing in influencing decision-making. Fear about the potential impact of expected cuts was tempered by the realization that they were not being treated as pawns but were highly valued by their managers and others in key nursing positions who were willing to fight for the principles and values of nursing.
Hamric (2001), who has written extensively about advanced practice, suggests that "one of the important lessons in the history of the evolution of advanced practice has been the strength that can result when nursing unifies and speaks with one voice." Having a shared vision has meant that there has been a common goal to be achieved and solidarity in striving for its achievement. The one voice, one vision concept will need to be fostered and supported. We need to continue to learn how to use our collaboration skills and processes.
In our institution, nursing leadership has chosen to invest in the development of advanced practice roles such as clinical nurse specialist and nurse practitioner to facilitate the professional development of nursing practice. These key roles are linked to the nurse managers and the nurse educators so that evaluation of client care, staff and systems will ensure linkages within nursing and across interdisciplinary teams. Each of these roles has been developed as resources to the clients, the nurses and the multidisciplinary teams to assist them in providing quality care, meaning care focused on the client. As a group of advanced practice nurses, we too are developing cross-site links and supports among ourselves to ensure that we remain connected and supported. Sharing ideas and mentoring one another has created avenues for support and growth within the advanced practice group.
In a recent weekend Globe and Mail column (Murphy 2003), the insightful author stated that "leadership isn't the act of showing up. It's the deed of staying around. Being seen to live each bitter moment of a trying time. Leaders don't intervene. They participate." In our profession of nursing, leaders have participated. We have invested much in the advancement of our educational programs and the development of our research knowledge. We have begun to have nurses in powerful positions from which they can influence decision-making at the highest level. These achievements were accomplished in part by a concerted effort to form collectivities, to understand and use research effectively in lobbying and negotiating. At this point, we need to reinvest the same energy in facilitating our frontline practitioners in their work with clients and families so that these nurses' commitments can be fulfilled. The fostering of strategic relationships within all levels of nursing departments is one sure method of helping nurses to stay at the bedside with pride.
About the Author(s)
Jane Chambers-Evans, BNSC, MSCA, MSC (Bioethics)
Clinical Nurse Specialist, Critical Care, McGill University Health Centre
Eureka Fellow 20022003, Adjunct Faculty, School of Nursing
McGill University, Montreal, Quebec
AcknowledgmentThanks are due to the clinical nurse specialists and nurse managers with whom the author discussed and debated these ideas.
Hamric, A. 2001. "Presentation on Advanced Practice." McGill University Health Centre, October.
Murphy, R. 2003. "Toronto Could Use a Moses, But It Got a Mel." The Globe and Mail, Saturday, April 26: A19.
Rodney, P., C. Varcoe, J. Storch, G. Macpherson, K. Mahoney, H. Brown, B. Pauly, G. Hartrick and R. Starzomski. 2002. "Navigating Towards a Moral Horizon: A Multisite Qualitative Study of Ethical Practice in Nursing." Canadian Journal of Nursing Research 34(3): 75102.
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