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The Critical Impact of Leadership in Nursing Today

Today' post comes to us from Nanne Finis, Chief Nurse Executive at UKG.

A special thank you to Anne-Marie Schenk, DNP, MBA, RN, NE-BC, UKG Chief Nurse Executive Advisory Board member, Nurse Executive and Founder of Lead.2Gether, who contributed her real-world nurse leader perspective to this article.

In my role as the Chief Nurse Executive at UKG, I have the opportunity to talk with and learn from nurse leaders across the U.S. Based on these interactions, here are some insights into the COVID-19 experience from the nursing perspective that healthcare leaders must pay attention to now.

This Pandemic is a Clinical Crisis.

COVID-19 has poured gasoline on the already difficult role of nurse leaders. Nurses and physicians have been the leaders in this fight, and it's evident that business leaders have had to rely on them to manage the business of healthcare like never before. This expanded responsibility for operational control has led to increased emotional burden and stress on nursing leaders, as they have borne increased responsibility for the success or failure of their organizations and have had to lead those they used to follow. The view of the organization through the eyes of the nurse leader portrays a uniquely different place than a year ago. Essentially, the goal for every nurse leader in 2020 was simply survival. The three most prevalent focus areas of nurse leaders and their organizations are:

  1. Focus on Finance

The surgical volume is the bread-and-butter of hospital finances and without this surgical revenue hospitals cannot survive. Labor costs associated with salaries as well as recruitment, retention and training are a major burden to hospitals. This fact, coupled with the loss of hospital revenues and increased non-labor expenses, challenged organizations to manage day-to-day finances without forecast or prediction models---knowing that the future was uncertain.

Nurse leader impact

Nurse leaders have been under constant pressure to keep the volume rolling, despite staffing, process, and often limited supply resources to support the volume. Nursing leaders have had to navigate the fine balance between finance and safety as many nurses have left  to take lucrative assignments elsewhere, leaving already understaffed units even more vulnerable.

2. Focus on Workforce

With the on-again-off-again elective surgical volume, hospitals have had to figure out how to keep staff working when elective surgeries were canceled. Once elective surgeries resumed, nurse leaders had to scramble to find staff to work on a dime. As the aforementioned travel contracts and "life-changing" salaries were offered (out of clear desperation), hospitals across the country began “recirculating” the same resources, leading to enormous salaries while driving down quality. States paid huge sums of money for crisis staff. In retrospect, many continue to wonder if this money might have been better-allocated by providing staff incentives to stay in their home organizations, still costing money, still allowing them to benefit, but not negatively impacting quality.

A February 2021 AONL COVID-19 longitudinal study report highlights many critical changes that have occurred since July 2020. The most critical data point from this study concerns nurse managers: 24% of the manager respondents indicated that they are not or not at all emotionally healthy. Nurse managers also are more likely than Chief Nurse Executives to leave the profession of nursing.

Nurse leader impact

For a nursing leader, staffing is simply their daily work; they begin learning staffing the first day on the job as a staff nurse. During COVID-19, approvals for incentives to increase staffing often came to organizations too slowly. These leaders likely knew what was needed but had little control over solving the problem. They were left powerless, watching the impact on both their staff and their patients. Absences due to exposures and illness crippled many nursing units. Many organizations were reluctant to monitor absences, because they were concerned this would drive staff to come to work ill. Some staff took advantage of absences without consequence, further burdening their peers, while others were simply caught between the desire to fulfill work commitments and their own personal time stresses, including childcare and schooling. Pre-COVID hospitals had attendance policies and procedures to keep absences in check, but those controls were no longer reasonable in this new environment. As the year progressed, maintaining the morale of staff became more and more challenging and further drained the leaders, who themselves needed a cheerleader.

Attention to the issues that impact nurse retention and wellbeing is a challenging but critical priority for leaders today. According to the AONL study mentioned above, managers and employees at all levels are experiencing stress and burnout symptoms in different ways, with those closest to point-of-care, including nurse managers, experiencing the highest levels stress.

3. Focus on Safety

The politics of COVID-19 bled into the workplace. Politicization of masking mandates and quarantine guidelines in hospitals often created hostility between non-clinicians and the clinical staff mandated to follow CDC guidelines. Process changes associated with COVID-19 (both for prevention of transmission and supply chain shortages) had to be designed and executed and the impact of staffing on patient care had to be measured in new ways.  Quality nursing care takes time and requires the application of consistent evidence-based practices. COVID-19 created significantly worse staffing and the increase of contract staff often negatively impacted compliance with care “bundles” and practice guidelines.

Nurse leader impact

Nurse leaders found themselves emotionally drained as they often had to defend the science and the regulatory requirements to their non-clinician peers. For the non-clinical leaders, it was just “opinion”. For the nurse leaders, their license, profession and job called them to drive safe care. This led to exhausting daily review and redesign of processes. Nurse leaders were responsible for creating new processes and executing on successful change. Errors most often are born from process errors, rather than people errors. Burnout related to negotiating the new processes with stakeholders and maintaining responsibility for any errors associated with the new process created additional burden to the leaders' emotional stability. Nurse leaders everywhere found themselves with a deep desire and professional commitment to deliver high-quality care to every patient in the face of limited resources created a constant state of distress.

A New Playbook is Needed

The work, the workplace, and the workforce have all dramatically changed in the last year and the nursing playbook must be completely rewritten and re-tested. Public health officials are still warning caution but also beginning to see reasons for hope as millions of people around the world are being vaccinated. We have depended on our nurse leaders for guidance during this time and we will continue to depend on their leadership for the future. We find ourselves at a daunting place, but one that may also be a time of innovation and change that will be professionally rewarding. 

There is emerging science and technology that can help to predict both workload and workplace stress that can hopefully be used to better plan for future pandemics where we can better support our nurse leaders.

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