How Nurse Leaders Drive Change and Affect Strategic Goals

Staff shortages and healthcare workers’ declining emotional health and well-being following COVID-19 are threats to healthcare safety for all.

While the focus has been on frontline nurses, the American Organization for Nursing Leadership’s (AONL) recent studies identify a negative trend that healthcare administrators neglect at their own peril: Nurse managers and directors are struggling under the weight of COVID-19’s effects both at a personal level and on behalf of their staffs, with little recognition. The studies show high levels of emotional stress and burnout and dramatically increased levels of resignations and intent to leave the profession. 

Nurse leaders coordinate nursing staff—the largest segment of the healthcare workforce and the one that spends the most one-on-one time with patients. In addition, they coordinate the work of many other disciplines to ensure patients and families are safe and cared for. As a result, nurse managers and directors have an enormous impact on the achievement of organizational goals. Effective nurse leaders:

  • Promote safety and help achieve quality and financial goals
  • Establish, support, and generate evidence-based nursing practice
  • Improve quality—from patient care to systems facilitation

Who are nurse leaders? 

Nurse managers, directors of nursing, chief nursing officers, and chief nurse executives are leaders who affect many frontline caregivers and guide and participate in change operations and policies. However, the American Nurses Association (ANA) stresses that every nurse is a leader and encourages all nurses to develop and demonstrate effective leadership skills. Importantly, there are opportunities to begin teaching leadership skills early on in nurses’ careers. 

Effective leadership requires numerous essential and diverse skills, and the most important ones vary depending on the situation and challenges at hand. For example, nurse leaders must adapt to constantly changing processes—such as regulatory and reimbursement requirements and evidence-based standards—in healthcare. Agility allows a nurse leader to implement rapid changes that benefit the organization without sacrificing momentum or losing sight of the overall goals.

The American Organization of Nurse Executives (AONE) publishes nurse executive competencies that detail the skills, knowledge, and abilities that guide nurse leaders in regardless of their educational level, title, or setting. Developed in 2004 by the Healthcare Leadership Alliance, the competencies are:

  1. Communication and relationship management
  2. Knowledge of the healthcare environment
  3. Leadership
  4. Professionalism
  5. Business skills and principles 

Within each of the five domains, AONE lists specific principles, skills, and practices. The organization states that reliability and validity of the competencies is established by periodic job analysis/role delineation studies. 

4 Must-know nurse leader organizations 

Numerous high-profile organizations support and advocate for nurse leaders in today’s healthcare climate where recognition of them is lacking. Importantly, they’re sounding alarm bells about changes to nurse leaders’ primary challenges and researching and publishing critical data concerning nurse leader well-being. 

  1. The American Organization for Nursing Leadership (AONL) is the national professional organization of over 10,000 nurse leaders and “the voice of nursing leadership.” Its mission is to shape healthcare through innovative and expert nursing leadership and promote professional development for nurse leaders through education, advocacy, and community. As noted, AONL recently completed a three-part longitudinal COVID-19 study of nursing leaders. 
  2. The DAISY Foundation (DAISY) expresses gratitude to nurses with programs that recognize them for the extraordinary skillful, compassionate care they provide. An acronym for Diseases Attacking the Immune System, the DAISY Foundation was formed in November 1999 by the family of J. Patrick Barnes who died at age 33 of complications of Idiopathic Thrombocytopenic Purpura. In addition to the DAISY Award for Extraordinary Nurses, which has been bestowed on more than 167,000 nurses, DAISY honors nurse managers, assistant managers, directors, charge nurses, educators, CNOs, preceptors, informatics nurses, patient flow nurses, and others with its leadership award
  3. The American Nurses Association (ANA) has a mission to lead the profession to shape the future of nursing and healthcare, and it states that effective nurse leaders “motivate and inspire others to work together to achieve shared goals, including the delivery of high-quality, safe, and evidence-based patient care. [They] provide vision, perspective, accountability, and expertise to support quality patient care and a safe, healthy work environment.”
  4. The American Association of Critical-Care Nurses (AACN) promotes healthy work environments that support and foster excellence in patient care wherever nurses practice. Its Standards for Establishing and Sustaining Healthy Work Environments (HWE) is a response to evidence that unhealthy work environments contribute to medical errors, ineffective care delivery, and conflict and stress among staff. AACN’s research shows that healthy work environments are more likely to have nurse leaders who fully embrace six HWE standards.

What's a clinical nurse leader?

Nurse leaders and other healthcare administrators identify two essential needs of nursing: 1) to improve patient care quality; and 2) to prepare nurses with the skills needed to thrive in the rapidly changing healthcare system. To meet these needs, the American Association of Colleges of Nursing (AACN) developed the Clinical Nurse Leader certification program. A Clinical Nurse Leader (CNL) is a master's educated nurse, prepared for practice across the continuum of care within any healthcare setting.

The CNL is a clinical leader at the point of care who:

  • Provides direct patient care (in complex situations)
  • Coordinates care, including care transitions
  • Measures clinical outcomes
  • Focuses on inter-professional communication and team leadership
  • Assesses risk
  • Implements evidence-based best practices  
  • Develops quality improvement initiatives

CNLs fulfill several key leadership roles, including:

  • Leading interdisciplinary teams. CNLs are skilled clinicians, patient advocates, educators and planners, team resources, and lifelong learners.

  • Changing care plans and implementing care initiatives. CNLs have decision-making authority to change care plans if necessary according to evidence-based practices and standards. On a larger scale, they work to change care systems to meet identified needs of groups of patients. For example, a CNL may work with a case worker to coordinate transportation for a dialysis patient. Recognizing that other patients share similar transportation needs, the CNL might develop a new initiative to address the problem and provide solutions system-wide.

  • Meeting the Quadruple Aim’s goals. Improving population health, reducing per capita healthcare costs, and enhancing patients’ and providers’ experience are all objectives within the CNLs’ purview. To achieve these goals, CNLs assess cohort risks, educate patients and care teams, apply evidence-based practices to deliver high-quality care, and collect and evaluate patient outcomes data.

What's the role of a nurse manager?  

Unlike CNLs, who work directly with patients and their care teams, nurse managers hire and supervise staff, coordinate and manage daily operations, and set and achieve goals for their areas. Their primary role is to inspire and motivate staff to achieve high-quality, patient-centered outcomes. They promote a safe and healthy care environment for employees, patients, and visitors.

Nurse managers:

  • Establish goals for the unit and ensure these goals are met
  • Manage, supervise, and mentor teams of nurses
  • Hire, train, and evaluate nursing staff
  • Set nurses’ schedules
  • Collaborate with other managers and other disciplines to offer a range of healthcare services and achieve optimal patient outcomes
  • Implement evidence-based practices
  • Oversee daily operations
  • Design and manage a budget
  • Oversee functions including financial outcomes, technology, and the utilization of clinical systems such as electronic health records systems
  • Serve as agents of change
Improving quality of care, patient safety 

Effective nurse leadership improves the healthcare industry in countless ways. The Institute of Medicine’s “The Future of Nursing: Leading Change, Advancing Health” report calls for nurses to be included as full partners (with physicians and other healthcare professionals) in redesigning the U.S. healthcare system. With strong, steady, and agile nurse leadership having a voice at the table, healthcare will improve. 

The National Academy of Medicine’s consensus statement, “The Future of Nursing 2020-2030,” calls for a new generation of nurse leaders—one that “recognizes the importance of diversity and equity and is able to use and build on the increasing evidence base supporting the link between social determinants of health and health status.” Teaching leadership must start with the courses required of nursing students.

Nurse leaders are instrumental in developing and delivering high-quality, efficient, and holistic healthcare. Studies have shown that nursing leadership styles are strongly correlated with care quality, and leadership is a core element for well-coordinated, integrated provision of care. One review examined the association between nursing leadership and patient outcomes. Results indicated that relational leadership—including practices such as coaching/mentoring others—led to better overall care in these crucial outcomes: higher patient satisfaction and lower patient mortality, fewer medication errors, decreased restraint use, and fewer hospital‐acquired infections.

Nurse leaders help establish and promote a safety culture for patients and staff by:

  • Recognizing and rewarding the reporting of errors and incidents
  • Increasing executive leadership interactions with staff on patient safety issues
  • Enhancing workforce knowledge about zero defects (i.e., no harm, infections, or needless deaths)
  • Improving communication regarding unanticipated outcomes
  • Informing staff of operational changes made after incidents are reported

How nurse leaders implement change and meet strategic goals 

Nurse leader executives (CNOs and CNEs) are responsible for setting and meeting organizational strategic goals. Strategic goals are the specific financial and non-financial objectives and results—such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) quality scores—a healthcare organization aims to achieve over a specific period of time, usually the next three to five years.

Nurse leaders have the right experience and skills to achieve strategic goals. The nursing process is similar to strategic planning. Both processes start with determining an end goal (e.g., the patient recovering from an illness) and examining the current status in relation to that goal (e.g., vital signs and lab results). Then there’s the development and implementation of a plan to achieve that goal (e.g., a care plan). The last stage is determining whether the plan/implementation worked or must be adjusted. Nurse leaders apply the skills developed through patient care and administrative duties to meet strategic goals.

Nurse leaders successfully implement changes in operations and policies by applying evidence-based change concepts. Specifically, they anticipate how staff will respond to change and choose the right leadership skills and implementation strategies to execute any plan. 

A Nursing Management article lists the qualities, skills, and characteristics that help nurse leaders successfully implement change:

  • Ability to combine ideas from unconnected sources
  • Ability to energize others by keeping the interest level up and demonstrating a high personal energy level
  • Effective communication and human relations skills: interpersonal, group management, and problem-solving
  • Integrative thinking: the ability to retain a big-picture focus while dealing with each part of the system
  • Sufficient flexibility to modify ideas if modifications will improve the change, but enough persistence to resist nonproductive tampering with the implementation
  • Confidence and the tendency not to be easily discouraged
  • Realistic expectations regarding how quickly staff will accept and perform new processes competently
  • Trustworthiness: a track record of integrity and success with other systemic changes
  • Ability to articulate a vision through insights and versatile thinking to instill confidence
  • Ability to handle resistance to a new process

Effective nurse leaders recognize that not all change is improvement, but all improvement is change. Nurse leaders can take advantage of workforce management and safety improvement software to help them create a safety culture and lead the delivery of high-quality, evidence-based care.

Establishing and maintaining a healthy work environment requires strong nursing leadership. Under prevalent models of servant leadership, shared governance, and staff empowerment, it’s common for nurse leaders to be less visible and go unrecognized for successfully implementing and leading shared decision-making models of care. We must value nurse leaders’ worth; support them through meaningful recognition programs, such as DAISY; show serious concern for the quality of their work-life balance; and empower them throughout their respective organizations. 

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