Interview with Debra Bournes
Dr. Debra Bournes began her role as provincial chief nursing officer in the Ontario Ministry of Health and Long-Term Care in June 2011. Previously, she was director of nursing, new knowledge and innovation at University Health Network in Toronto. Dr. Bournes has had a leadership role in healthcare research and administration for more than 17 years. She is known nationally and internationally for leading and providing consultation about patient-centred care, academic practice and professional development for nurses, research culture development, proactive health human resources analysis, Web-enabled innovations and communication tools, digital signage, care model reviews and reports, strategic planning in nursing, organization-specific and provincial nursing resource teams and quality workplace/quality patient care indicator dashboards for healthcare leaders. In 2008, Dr. Bournes received the University of Toronto Bloomberg Faculty of Nursing Award of Distinction and the Ontario Hospital Association Award of Excellence in Nursing Leadership. In 2009, she received the RNAO Leadership Award for Nursing Research for her work on developing a research culture among nurses in staff, advanced practice and leadership roles. Dr. Bournes recently spoke with Lynn Nagle about nursing and what the future may hold.
Why did you go into nursing?
DB: I was a competitive swimmer and a lifeguard and did a lot of first aid, and it was natural to go into a healthcare-related field. Like a lot of young people, I chose it out of an interest in the science. The reason I stayed in nursing is probably more interesting than why I went into it: I went through the motions of my undergrad, but once I was in practice, I realized what a huge opportunity and responsibility nurses have to make a difference, to be with people and families at some of the most vulnerable times of their lives. I also realized there were a million different opportunities and every day was different. The connections I made with patients and families early in my career are what kept me in nursing.
Now my practice is more of a leadership practice. My best days are when I get to connect with nurses at the point of care who are making a difference to patients and families, helping them to be leaders and to improve patient care or the quality of work environments. It's still an opportunity to make a difference in people's lives.
Were you surprised by anything about nursing as a profession?
DB: I think my biggest surprise was how many opportunities there actually were. … There's a million places that you can work doing direct patient care, and there's a lot of opportunities to be a leader while providing it.
What does "leadership practice" mean to you?
DB: When I was a staff nurse, my mentors encouraged me to serve on committees and to participate in activities that were broader than my one-on-one, day-to-day practice. I found I loved to do that as much as I loved to provide patient care. These were ways to see what was happening in the broader system. Then I had opportunities to move into leadership roles and realized that I could still make a difference and be excited about what I did working with other nurses and health professionals to address and improve patient care issues.
What made you decide to pursue graduate studies in nursing?
DB: I enjoy learning, but I also realized that in order to pursue a leadership role, I needed more exposure to a broader range of ideas, and a knowledge base, than I had at the time. I knew that going back to school would also help me to connect with the broader nursing community. I participated on a hospitalwide committee in one particular organization, and Dorothy Pringle came to a meeting and started talking about the new Nurse Practitioner master's program at the University of Toronto. I remember thinking, "Wow, that's what I want to do." I never became a nurse practitioner, but graduate studies opened my eyes to the fact that there was more to nursing than what I was currently doing. I wanted to be engaged in that, and it excited me. I thought, "Okay, I'm going to do my master's and then we'll see what happens."
But when I started looking at different leadership roles and thinking about some of the things I wanted to influence, it seemed important to go on and pursue a PhD. The degree puts you on more of a level playing field with some of the other professions and some of the other people in leadership roles across the system; that's important. Also, I was excited about learning more about research and doing some of my own. That was probably one of the best decisions I could have made, because a lot of the work I've done in recent years has involved not only my own research, but helping others to generate innovations and evidence that have contributed to system changes.
Is there any single piece of work that that you think has made a significant contribution to the profession or to clinical care?
DB: I've always focused on client-centred care. In the early days, considering the concept of safe, patient-centred care, and examining how we interact and relate with patients and families, was a fairly new and foreign concept, and not so popular in the beginning. It was one of the things that drove me to continue in my leadership pursuits, because connecting with nurses and other health professionals about how to relate with patients and families – understanding how to engage them in conversation about what's important to them and what would be helpful – gave me a lot of satisfaction when I could see that it helped the professionals and the nurses I was working with, but also when it made a difference to patients and families.
One of my first roles as a professional practice leader was also my first experience with a wonderful nursing mentor. She taught me how to be a leader and how to stay engaged with what I was passionate about, even when it got hard, because to see that you are making a difference, even if it is a little bit at a time, is really worthwhile. Now, patient-centred care has grown and flourished across the healthcare system; most organizations have some sort of philosophy about it. In many places it means being with patients and families in ways that honour who they are, what they want to have happen and what's important to them. There is a Best Practice Guideline related to it, and it has taken on a whole new meaning. I'm proud of that, because that, to me, is what matters and why we're all there.
Do you think that patient-centred care has been actualized in a prevailing way, or do you do think that we still have work to do?
DB: I think we're never going to be done. I think it's one of those things that we need to keep our eye on forever. … In some organizations, I think that people say they're patient-centred but they haven't done the work of asking, "What does that really mean? How would that change what we do on a day-to-day basis – how we approach people, interact with them, set up and evaluate our services?" I think it depends upon the organization.
There are pockets of excellence where they've been able to show that patient satisfaction scores are better. When we do qualitative interviews with patients and families, they talk about how they're respected differently and how they notice a difference in staff in comparison to other places. So I think it's a "forever" job because it's tough, and part of it is linked to creating high-quality work environments for nurses and the other professions who expect to work differently with patients and families; because if [the professionals] are not supported and they're not treated the way we expect them to treat patients and families, they can't [do the work]. It's a double-edged sword – you have to have both.
Are there other aspects of your work that have given you a sense of pride?
DB: I'm proud of some of the work that I've done combining my passion for patient-centred care with developing nurses at the point of care as leaders. Studies have shown that patients and families noticed a difference in nurses who are focused on patient-centred care. Nurses themselves had reduced sick time and overtime, and stayed in their jobs because they could deliver the care that they were passionate about and had the time to contribute to mentorship and a high-quality work environment. … I believe we underutilize nurses; we don't expect them to lead from where they stand. I think that there needs to be a lot more focus on what they're able to do, because that's what's going to keep them employed and satisfied in the workplace.
What do you think are the key ingredients to keeping nurses satisfied in their work?
DB: They want an opportunity to engage in either leadership activity or ongoing professional development. They all talk about wanting to have good relationships with their colleagues, and coaching and mentoring opportunities with their direct leaders. Everybody wants to make some contribution to the team, … to suggest ideas and be supported to try out innovations that can make a difference to the work environment and also to patient care. At the heart of it all, nurses are there because they want to make a difference to patients and families.
Whenever I've asked nurses, "When you have a wonderful day at work, what does it look like?" they talk about the times when they went that extra mile to do something for a patient or a family member, or how it made a difference to someone's life by connecting with them. Very rarely do they say, "When I got the IV in the first time"; it's more the relationship piece. They lose that sometimes because of the busyness, or it's not always an expectation, or there is no support for it.
I know it's early days, but can you give me a sense of your thoughts about potential hurdles and challenges that lie ahead in your new role as Provincial Chief Nursing Officer?
DB: We have a nursing strategy in Ontario to ensure that we have the right number of professionals in the right place at the right time, and that nurses have the proper education. There's been a lot of work done in terms of creating more full-time opportunities for nurses and providing educational opportunities. Funding programs are directed to help recruit and retain nurses at both ends of their career. I think the opportunity in this role is to determine how can we work with the priorities of both government and the nursing community. We need to provide opportunities to ensure high-quality work environments, for leadership development and to get nurses involved in research and innovation at a broader level. I'm hoping that I can work through this role to influence that, and to engage with the province's stakeholders.
As for the challenges – I'm trying to see them as opportunities. We have a huge stakeholder diversity in nursing in Ontario, and I've met with many of the key representatives from some of the major groups. I think that there's incredible opportunity to harness their commitment to their shared values. They all have a deep wisdom about what they want to have happen. They all care about patient care and what happens to the nurses who are providing that care. I think there's an opportunity there to capitalize on that.
I think that workforce sustainability is always going to be something we have to keep our eye on. Nurses are coming out of school expecting to be employed differently than they were in years past. They want to be leaders in their own way, to engage in research, to engage in different opportunities. We need to look at how to create opportunities and new roles, such as RN surgical first assistant or patient and discharge navigator. Those are the roles that are going to keep nurses interested and able to innovate, which will help to recruit and retain them in the profession.
From my vantage point, we still have a lot of silos and fractures in the continuum of care. I believe that we need to figure out how to harness the wisdom of all the nurses in the system, because they're out there plugging the holes in those fractured continuums right now. We need to find ways to enable the workforce to be mobile across the sectors. I think we have a great opportunity for nurses to create models of care and service that enhance the system's ability to deliver across the continuum. That will also help with sustainability because it'll challenge nurses to be innovative and to put forth their ideas and make them happen.
Of all of those opportunities, what do you see as key to the future of nursing across the country?
DB: We need to work on leader succession planning … to focus on developing nurses as leaders at the point of care so that they can improve their work environment and the quality of patient care.
When I talk to people, I hear that there's a limited number of nurses who are willing and available to work in the nurse manager role. We know that role is one of the most difficult, but I also believe that it's one of the most critical roles to patient care and staff nurses. If we can help the nurses at the point of care to take on leadership for certain things, it will also provide relief for the manager. But then how can we also work with managers to have them to interact differently with the staff nurses when they are assuming leadership responsibilities? The manager needs to provide more coaching and mentoring support. Developing and expecting more in terms of leadership from nurses at the point of care will help to prepare more of them to want to take on the manager role and also other leadership roles in the future.
When I talk about nurses I mean all nurses, not just the registered nurses, but also registered practical nurses and nurse practitioners. We too often focus on just the RNs or just the NPs. I believe that there's a huge role for all categories of nurses. It is important to look at who is the right person to provide the care in any given situation.
What advice would you give to emerging nurse leaders as important to their success and achieving their professional goals?
DB: Nurses need to go out and make connections with people who might not otherwise connect with them. If nurses want to make something happen, they need to go out and pursue it – to decide what's important to them, what they stand for. When I think about what makes a successful leader I always come back to Parse's (1997) leadership essentials: commitment to a vision, willingness to risk and reverence for others. Nurses need to have the commitment to a vision. For me, it's patient-centred care and high-quality work environments; everything I do connects with that in some way. And they need to be consistent about engaging in opportunities to advance whatever they're committed to. … Everything they say, everything they do, how they show up, how they think, how they act needs to be consistent with what they say they stand for. People will listen to them then because they will see that [their commitment] is genuine.
Nurses need to be willing to take risks. I believe that the difference between good leaders and great leaders is their willingness to risk. There's never enough time, there's never enough money and you can never have all the i's dotted and the t's crossed. You need to be willing to do what other people won't do to make things happen.
Also, I believe that 99.9% of being a successful nurse leader is your relationship with others. Reverence for others doesn't always mean agreeing with everything everybody says but having a discussion, being frank, engaging others and honouring what they know.
So leadership is three things: standing up for what you're passionate about and committing to that vision; being willing to take risks; and living reverence for others in everything you do. Whenever I do anything as a leader, I think, how am I showing that this is what I'm passionate about – that if I say this, I am also doing this, and can people see that? Do they know that no matter what happens, this is what I'm going to stand for?
Years from now when you decide to retire, what do you want people to say about you? What you would like your legacy to be?
DB: I want to be known as a person who focused first and foremost on nurses at the point of care, and who stayed connected with those nurses and helped to change how we employ and provide mentorship to them, to support them to be leaders. … Staff nurses are amazing, and they can do whatever we support them to do.
If you had a crystal ball and you could have a vision for nursing in the next decade, what would it look like?
DB: I hope that we will have moved a long way and nurses will be employed differently – see themselves as leaders with the ability to make a difference rather than sit back waiting for somebody to change things for them. I hope it will be normal versus novel for nurses to be leading their own research and innovation projects that are aimed at improving patient care and the quality of work environments.
I hope that all nurses – RNs, RPNs and NPs – will work collaboratively across the continuum of care, and that we will have found some way to enable mobility across the healthcare sector so that people who are experts in, say, oncology care in acute care settings would be able to move out into the community, if they wish, without losing their seniority or their pay. Somehow, we have to find ways to make that happen. I think that nurses will be leading innovations that break down the sector silos in improving continuity of care. I hope that we're going to have multiple new roles that bridge the gap in access to care, which will help Ontario – and hopefully, the country – to achieve excellent care for all our citizens. That's really the bottom line: providing high-quality healthcare for the citizens of Ontario and across the country.
We'll have figured out how to ensure that we have the right number and types of nurses to provide healthcare … so that all nurses will be able to stand up and say they feel proud and respected for what they're doing.
I want nurses to be known as significant contributors to quality of care and safe work environments. We need to look at what's good for patient care. I think if we always focus on that, what's good for nursing will follow.
Parse, R.R. 1997. "Leadership: The Essentials." Nursing Science Quarterly 10: 109.
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