Leadership and Nursing

The Nurse. Two words. Words that historically would bring forth a mental image of the caregiver, the angel in white, tending to the needs of the sick, the needy, and dying. An image formed on battlefields and in hospital wards. The Nurse was respected and emulated. Little girls “nursed” their dolls, bandaged their “boo-boos”. Someday they would grow up to be The Nurse, and be proud of the profession they had chosen. They would comfort their patients; give good care, holding the hand of the mother during childbirth and the hand of the elderly as they died. Know each day that they were making a difference in the lives of others, and in this pride there would be the call to others to become The Nurse too. Supporting each other, as well as those that would come after them. Until the day that The Nurse started to ask the question, as described by Malloch & Porter-O’Grady, “why do I feel so bad”?

Within the past decade, the nursing shortage has presented many faces: fewer persons are interested in nursing as a career, enrollment in nursing programs has dropped, and fewer nurses are being employed by hospitals. Increasingly, nurses are expressing dissatisfaction with their practices. Toxicity in the workplace has been a major cause of the decreased interest in nursing. When the conditions of the workplace began to effect practitioners, and practice, to the point that nurses questioned their own value, I believe it was then that the lack of interest in nursing began.
Workplace toxicity has continued to foster a “glass half empty” view among many practicing nurses. Disappointed, overworked, and overwhelmed, nurses stopped promoting themselves, as well as nursing, as a worthwhile profession. A consistent “dissent in the ranks” has led to mistrust and decreased sense of comradery among staff. This lack of satisfaction has several causes, but similar outcomes: decreased retention, (especially among specialty nurses); frequent turnover; early retirement; and/or departure from nursing altogether. More foreign nurses, travel nurses and agency nurses are used to maintain staffing levels. The changing composition of the nursing workforce and the dissatisfaction of practicing nurses contribute to the complexity of the nursing shortage. (Donley, 2005). In a profession where healing of others has been the focus, the struggle at this time is to try to heal itself.
The causes of the nursing shortage are multi-factorial. During the 1990’s, the change in health care reimbursement structures led to fewer nurses being employed, especially within hospital settings. The structures that promoted nursing orientation, education, and training were eliminated because these were perceived as “non-essential”. These systems of internal support essentially disappeared and it became a “sink-or-swim” environment. This amounted to professional poisoning, and potentially professional suicide. As my interest goes to being a nurse educator in multiple environments, academic education as well as within a practice setting, I think that these supports need to be returned. I feel that nursing needs to protect, preserve, empower, recruit and retain within what it has right now. Many nurses see the solution to the problem as being more “bodies”, through recruitment, bonus structures and job incentives. These programs, although well intentioned, may not be enough in spite of best efforts because of factors beyond the best recruiter’s control.
Unlike other periods of nursing shortage, the profession itself is now also influenced by the same societal demographics that are causing the problem. The aging of the Baby Boomer generation is influential in the increased need for nurses, but the majority of practicing nurses are part of the same demographic. This affects clinical as well as academic settings, as many of the Masters and Doctoral prepared are also aging, with new educators not entering the teaching setting. As of 2000, 60% of the nursing workforce was over 40 years of age, and the percent of RNs under age 30 had fallen by nearly 40% since 1980. It was estimated that nearly half of the nursing workforce would reach retirement age between 2010 and 2015. (Buerhaus, Staiger, & Auerbach, 2003). The succeeding generations have had different options, as well as being significantly smaller in number, as birthrates have decreased. The increase in educational opportunities, particularly for women, has made differences among the generations. Understanding the quantitative, as well a qualitative differences, is vital in shaping nursing workforce policies, and attracting new members to the field. Nursing has to see the shortage differently, in order to seize opportunities for growth in other ways. It is perhaps impossible to increase in number when the population itself is smaller, and of that population, opportunities are more varied (Donley, 2005).
What are the leverage points that nursing must promote? From the perspective
of an educator I believe we must start there. Education of new nurses, current nurses, and most importantly, of the public at large. Where do we begin? Foremost, nurses have to promote nursing! There is no way to attract new practitioners, or keep existing practitioners, if nurses continue to be entrenched in negatives. Identity is the biggest leverage point that one can have. Knowledge of who you are, what you bring to the table, and what you stand for should be the basis from where all else flows. Nurses must establish, promote, and be proud of their identity. Increasing the nursing “voice” and being seen as being important, with significant societal impact will break the stereotype of being “second tier” to physicians. Having an increased feeling of control over practice and decision–making and being a collaborator in care comes with confidence in clinical knowledge and the nurse’s professional role. Become political. Increase media savvy, and use the media to increase the image of nursing and deflate long held stereotypes.
Nursing education itself must rise to the “new occasion”. Nursing education remains hospital-centric, when the majority of health care is delivered outside the hospital setting. Future models have to promote independence and critical thinking, problem solving and analytical skills in order to keep pace with challenges in health care. Patient care and curriculum development will be based on evidence, clinical indicators, consensus and best practice. Faculty and staff development educators will need to add content, educate in multiple formats (technology) and follow knowledge almost as it is being discovered. Nurses have to be mentored and fostered in confidence throughout their educational process, and have to understand that their learning will be life-long. I think that nurses have been socialized to think that once you “are a nurse”, that is it. It is from that mentality that the fear and reluctance to continue education, therefore the professions inability to create a viable succession, has come. In leadership within an organization, one must learn how to recognize and foster succession. We need to do that in nursing. From the beginning, nurses need to be “educated to educate” those that will come next, in whatever context that takes (e.g: preceptorship), as opposed to the often described “eating the young” phenomena. Faculty must overall, help students find meaning and calling in their practice.
What resources do we need? We have ourselves as our most valued resource, and we don’t cost anything. The linear-thinking mentality of “when…..then” is self defeating because “when” may not come. The many financial and system related obstacles that effect nursing are generally not within our locus of control. In that, we need to use ourselves in the ways previously stated. With increased credibility, there is attention, respect, and often money. Investment must be fostered. Promotion of education, through accessibility and affordability, will increase the number of advanced practice nurses; thus adding to professional credibility. With this, financial gains may then be commensurate. Nursing has long been perceived as a woman’s job. Not the career of an educated, responsible, professional as has been the perception of the roles maintained historically by men. Increased pay is well deserved, but in this health-care environment, it is an uphill battle that will be won only based on criteria more measurable than years of service. Increasing career satisfaction though an environment of respect and support from our own administration is imperative. As stated in my self-assessment, I believe that staff empowerment in all settings is the key to satisfaction and productivity in even the most trying circumstances. People feeling they are being listened to. Feeling empowered and valued increases the health, energy, and harmony of a system. When the system is broken down by stress and dysfunction, the toxic environment is formed. (Malloch & Porter-O’Grady, 2003).
In their discussion of organizational toxicity, Malloch and Porter-O’Grady identify ten sources of this dysfunction. With regard to the educational setting, I will discuss four toxic behaviors:

· Vertical Authority Structure
Within nursing schools and institutions, there has long been a hierarchical mentality. With pressure on faculty/managers to maintain enrollment/productivity, and standards, and with obtaining tenure/standards of care as often being a motivating factor, a toxic environment can be fostered due to the stress on the instructor/manager to perform, with the needs of the student /staff being lost in the process. With regard to faculty/staff collaboration, this structure can often stifle creativity and expression due to the need to stay within the structure.

· Abuse of Power
The abuse of power is toxic in any environment. This may come from the frustration, insecurity, or poor preparation of the leader, be it a nurse educator or a nurse manager on a unit. The ensuing demoralization that ensues for the student or staff may be irreversible. Particularly in nursing education, where there is a human factor as well as a straight “three R’s” type of learning, there is an increased anxiety factor. If an educator/manager/preceptor comes from the aspect of “learning through fear”, that can effect a students/staff integration, confidence, and ultimately, their success.

Inconsistency and Dishonesty
I think this behavior is extremely detrimental in the educational, as well as work environment. Just as a clinical practice nurse is responsible for the honest and consistent care of their patient, I feel so is an educator/preceptor for the care of their student. Being open, honest, and communicating regarding progress, strengths and weaknesses is imperative. In my original AD RN program I witnessed poor educational leadership examples with regard to “ambushing” students, and at times embarrassing them publicly. These were cases where students had no idea that they were being perceived as weak until they were ultimately made examples of. Inconsistent and “mixed” messages and at times, outright lies. An educational environment should allow for trust, as students are relying on the educator to guide their future; not cause them to question it.

Toxic Mentoring
Educators/preceptors should not bring their “baggage” to the learning environment. Self-awareness is necessary to lead in any capacity, and this includes the ability to be able to allow others to just “be”. Being an effective educator does not mean that one should try to create others in their image, and discount those that do not aspire to be in that image. Sharing experiences as a way of healthy mentoring reinforces the need to learn over a lifetime. As I have stated, nurses have to be given the positive educational experience so as to desire to continue to learn, as well as teach so as to allow for succession of competent practitioners.

I hope as an educational leader in multiple settings to be able to transform educational experiences to as positive as they can be. Different environments will call for different approaches. Academia allows for some more control than a practice setting, so adjustments will have to be made. Hopefully, in trying to incorporate my leadership style into these, in nurturing my own flexibility, I will be able to reach nurses on a level that will stimulate them to want to know more and do more. Nursing will continue to face many challenges to it’s identity and sustainability due to economics, demographics, and politics, but if in being part of the growth of a nurse, I can plant some seeds that may someday become a garden, then I will have accomplished my goal and hopefully helped them on the road to accomplishment of their own.

References:

Bauerhaus, P., Staiger, D., & Auerbach, D. (2003). Is the current shortage of hospital nurses ending? Health Affairs, 22(6), 191-198.

Donley, R. Sr. (2005). Challenges for nursing in the 21st century. Nursing Economic$, 23 (6), 312-318.

Porter-O’Grady, T, & Malloch, K. (2003). Quantum Leadership. A Textbook of New Leadership. Sudbury, MA: Jones and Bartlett