«Nursing and Midwifery Office, Queensland The nurse executive role in quality and high performing health services: a position paper The context of ...»
Nursing and Midwifery Office, Queensland
The nurse executive role in quality and high performing health services:
a position paper
The context of nurse executive leadership
In complex and rapidly changing healthcare environments, nurse executives are challenged to lead within
organisational systems to fulfill regulatory, health consumer (patient), family, physician and staff
expectations, and provide excellence in nursing and midwifery practice across care environments (Parsons & Cornett, 2011; The Kings Fund, 2011; Patton & Pawar, 2012).
Nurse executives are in a unique position to influence change in healthcare and the quality of patient care by virtue of their combined professional and executive mandate. Nurse executives are aware of, understand and respond to political imperatives and the impact on health service delivery and nursing and midwifery practice (Talbert, 2012).
This position paper provides an overview of the available and relevant literature as it relates to nurse executive positions in health services.
The nurse executive role International literature provides supportive evidence that health services benefit from having established nurse executives through leadership structures for professional nursing governance. The benefits to organisations are realised directly through higher standards and quality of care with improved health consumer experience and positive health outcomes (Kirk, 2008; Machell, Gough & Stewart, 2009).
As the largest healthcare workforce, nurses and midwives have a significant influence on the optimisation of health service productivity and effective patient health outcomes (Buchan & Aiken, 2008; Cathcart, 2008).
Executive nurses lead and provide stewardship to the nursing workforce through professional governance standards to provide the care and quality experience that the public expect.
Executive nurse roles are differentiated from other nurses is their strategic capacity to:
influence at the highest organisational level provide advice and work across multiple areas relating to the healthcare business-patient experience understand and translate systems, budgets, strategy and models of care;
apply critical thinking skills, varied expertise, knowledge and extraordinary interpersonal capabilities (Upenieks, 2002).
Nurse executives are capable of creating a compelling vision for the professional practice of nursing and midwifery through strategic thinking, workforce and organisational development, and business planning to provide safe and reliable care to achieve service transformation through engagement with the nursing and midwifery workforce. More broadly executive nurses can create and lead clinical practice; influencing the degree of innovation and excellence at every level of a healthcare organisation (Batcheller, 2010; Talbert, 2012).
Attributes of an effective nurse executive Kirk (2008), through a systematic review ofinternational literature, identified ten factors consistently
associated with the attributes demonstrated by nurse executives:
1. powerful influential operator
3. knowledge of nursing
4. human management skills
5. total organisation view
6. quality management
7. business astuteness
8. collaborate effectively in multi-disciplinary teams
9. providing nurses and midwives with the right tools and resources to do their jobs
10. project management.
Further to Kirk’s (2008) findings, Machell, Gough and Stewart (2009) identified that nurse executives have a
key role, in conjunction with other executive members, in:
fostering the culture and climate to have open discussions about care quality and the health consumer experience leading and influencing by example and constantly reinforcing the importance of clinical quality to all aspects of the business of healthcare leading discussion and review of the information the health service board (board) want and need to know in order to assure quality presenting, analysing and interpreting clinical outcome intelligence and identifying the clinical impact of that data conveying and interpreting information about the health consumer experience through the use of soft intelligence and compelling narrative enabling boards to capture and respond to the emotional content of the health consumer experience role-modelling appropriate behaviours around presenting and receiving negative feedback for and about health consumers.
In a recent article, the role and positive benefits of nursing leaders on influencing effective procurement were detailed with reported significant cost savings and improved patient safety as a result of standardised use of equipment and supplies (Sunderland, 2013).
In summary, the effectiveness of the nurse executives within health services and boards is demonstrated through their leadership in 1 - professional governance, 2 - quality improvement, 3 - service transformation and change and 4 - shared governance.
Professional governance Nurse executives play a vital role in ensuring that there is a professional lead with visible authority, who is accessible and can act as an advocate for nurses and midwives within a health service at the executive and board level (Duffield, Kearin, Johnston & Leonard, 2007). The absence of professional leadership through to the executive level can result in a demoralised nursing and midwifery workforce with increased staff turnover (Duffield, Kearin, Johnston & Leonard, 2007; Duffield, Roche, Blay & Stasa, 2011).
By taking steps to ensure that nurses and midwives work in an empowering work environment and leading by example, nurse executives create a culture which is foundational in creating a work environment of collaboration, team-work, and shared governance (Clavelle, Drenkard, Tullai-McGuinness & Fitzpatrick, 2012; Havens & Aiken, 1999; Hayes, O’Brien-Pallas, Duffield, Shamian, Buchan, Hughes, Laschinger & North, 2012; Laschinger, Wong, McMahon & Kaufmann, 1999; Upenieks, 2003).
The nurse executive can provide balance within the executive team and for board decision-making between the provisions of integrated health consumer care, delivering key health service targets of financial integrity and resource investment planning. In addition, the nurse executive can drive a system-wide approach in support of health consumer care through strategically monitoring and maintaining more efficient and effective nursing and midwifery care in tandem with contributing to the development and implementation of organisational strategies to achieve key service performance targets (Stichler, 2006).
Approved by Dr Frances Hughes, Chief Nursing and Midwifery Officer, NM001864 version 3, 9 September 2013 Page 2 of 6 http://www.health.qld.gov.au/nmoq/publications.asp Quality improvement The nursing and midwifery workforce plays a crucial role in providing direct healthcare to consumers and service users. Strong nurse executive leadership positively influences clinical practice and care outcomes within health services through well led and managed nursing and maternity services.
The nurse executive has been evidenced as valuable in the promotion and advocacy of nursing in contemporary healthcare delivery, as they have the ability to influence structures and processes across various levels of the organisation (Talbert, 2012).
Nurse executives promote continuous improvements in advancing safe, health consumer centred, timely, efficient and cost effective quality care, which is health consumer centred, through leadership of the nursing and midwifery workforce (Adams, Erickson, Jones & Paulo, 2009). They achieve this while also maximising the criterion standard measure of success for healthcare organisations, health consumer outcomes, such as satisfaction, mortality rates, and hospital admissions (Adams, Erickson, Jones & Paulo, 2009).
Service transformation and change Service transformation and new approaches to providing care can be achieved through the use of the nursing and midwifery workforce, which requires strong professional leadership and vision. The nurse executive creates the framework for practice and provides the mandate and the infrastructure for excellence and innovation at every level of nursing and midwifery practice (American Organization of Nurse Executives, 2005; Porter-O’Grady, 2009).
Shared governance – clinical governance Shared governance is key to promoting a culture of health consumer safety and guides organisation revision.
The nurse executive works with other lead clinicians and the executive team, using the principles of shared governance, to guide service transformation and clinical governance through information sharing, idea generation for improving health consumer care, consensus building between health team members, fostering individual accountability and increasing team responsibility (Chiarella, 2008; Beglinger, Hauge, Krause & Ziebarth, 2011; Newman, 2011; Swanson & Tidwell, 2011).
To ensure good clinical governance, the nurse executive:
engages with the executive team to consider all aspects of clinical governance and to be accountable works with other members of the executive team to secure the support of their chief executive to engage the board on quality issues and the process of assurance about clinical quality builds alliances with executive colleagues exercises their professional and clinical expertise, in collaboration with the executive medical director, as lead executive clinicians, by developing collaborative relationships that support aligned effort in clinical activities uses any opportunities for peer support and networking with nurse executives from other organisations.
Relationship with the health service chief executive and board When there are high profile failings in health consumer care, it is often the nurse executive who is identified as failing to champion quality, patient safety and clinical governance at the board level (Machell, Gough & Steward, 2009; Mid Staffordshire NHS Foundation Trust Public Inquiry,2013). Therefore it is essential the nurse executive is supported by robust reporting processes around clinical quality and interfaces with a board environment that is transparent and concerned with quality improvement and clinical governance.
With the support of the health service chief executive, nurse executives are well placed to take an
authoritative lead and assist the board in the following areas:
the quality of clinical care and clinical engagement provision of expert interpretation regarding the purpose and context of nursing related data sets and what the data illustrates translation of board decisions as they would impact on patient experience and the standard of patient care provision of expert clinical perspective to assist colleagues to interpret the data and make sound decisions.
Approved by Dr Frances Hughes, Chief Nursing and Midwifery Officer, NM001864 version 3, 9 September 2013 Page 3 of 6 http://www.health.qld.gov.au/nmoq/publications.asp
ConclusionThe evidence is clear; executive nurse leadership plays a central role in providing strategic, expert, evidence-based advice to Boards and ensures that policy, macro decision-making, purchasing, reporting and monitoring are contextualised within the realities of individual patient care and population health settings.
The leadership role of executive nurses includes, risk management, business planning and development, and implementation and monitoring of funding models; positively shaping services to be effective while gaining the greatest yield from funding reforms. High performing, high quality healthcare organisations have executive nurses partnering with chief executive and medical leaders. Many countries require nurse executive positions in health services as part of accreditation, licensing and to meet legal requirements (Centre for Healthcare Improvement, Queensland Health, February 2012).
The role of nursing leadership at the executive level is vital role to supporting the delivery of efficient, safe and effective quality health service. The nurse executive is an asset to health organisations and should be valued for their essential expertise and leadership in driving the delivery of quality health care for the health consumer.
Approved by Dr Frances Hughes, Chief Nursing and Midwifery Officer, NM001864 version 3, 9 September 2013 Page 4 of 6 http://www.health.qld.gov.au/nmoq/publications.asp
ReferencesAdams, J., Erickson, J., Jones, D., & Paulo, L. (2009). An evidence based structure for transformative nurse executive practice, Nursing Administration Quarterly, 33(4), 280-87 American Organization of Nurse Executives (2005). AONE Nurse Executive Competencies. Nurse Leader, 3(1), 15-22.
Batcheller, J. (2010). Chief nursing officer turnover: an analysis of the literature. The Nursing Clinics of North America, 45, 11–31.
Beglinger, J., Hauge, B., Krause, S., & Ziebarth, L. (2011). Shaping future nurse leaders through shared governance. Nursing Clinicians of Northern America, 46, 129–135.
Buchan, J. & Aiken, L. (2008). Solving nursing shortages: a common priority. Journal of Clinical Nursing, 17(1), 3262–3268.
Cathcart, E. (2008). The role of the chief nursing officer in leading the practice: lessons from the Benner tradition. Nursing Administration Quarterly, 32(2), 87–91.
Centre for Healthcare Improvement, Queensland Health. (2012).Model Governance Framework for Clinical Safety and Quality in Local Health and Hospital Networks. Retrieved http://qheps.health.qld.gov.au/schsd/docs/dist/lhhn-mgf.pdf Chiarella, M. (2008). New and Emerging nurse led models of primary healthcare [Discussion Paper].
Canberra, Australian Capital Territory: Australian Government National Health and Hospitals Reform Commission. Retrieved from http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/16F7A93D8F578DB4CA2574D7001830E9/$ File/New%20and%20emerging%20nurseled%20models%20of%20primary%20health%20care%20(M%20Chiarella).pdf Clavelle, J., Drenkard, K., Tullai-McGuinness, S. & Fitzpatrick, J. (2012). Transformational leadership practices of chief nursing officers in Magnet® organizations. Journal of Nursing Administration, 42(10), 3-9.
Duffield, C., Kearin, M., Johnston, J., & Leonard, J. (2007). The impact of hospital structure and restructuring on the nursing workforce. Australian Journal of Advanced Nursing, 24, 42–46.