Clinical Nurse Leader
Workshop:
Leadership/Systems
Dr. Kia James, EdD, RN, CNL
CLINICAL NURSE LEADER
• How did the role come about?
• What were precipitating factors/studies/reports that
helped innovate this new role?
• What is this role supposed to do?
• Define the role
10 Assumptions for
cnl role
1.
2.
3.
4.
5.
Practice at the microsystems level
Client care outcomes are measure of quality practice
Practice guidelines are evidence-based
Client centered practice is INTRA- and INTER-discplinary
Information will maximize self-care and client decisionmaking
6. Nursing assessment is the basis for theory and knowledge
development
7. Good fiscal stewardship is a condition of quality care
8. Social justice is an essential nursing value
9. Communication technology will facilitate the continuity and
comprehensiveness of care
10. The CNL must assume guardianship for the nursing
profession.
10 Assumptions for
cnl role
1.
2.
3.
4.
5.
Practice at the microsystems level
Client care outcomes are measure of quality practice
Practice guidelines are evidence-based
Client centered practice is INTRA- and INTER-discplinary
Information will maximize self-care and client decisionmaking
6. Nursing assessment is the basis for theory and knowledge
development
7. Good fiscal stewardship is a condition of quality care
8. Social justice is an essential nursing value
9. Communication technology will facilitate the continuity and
comprehensiveness of care
10. The CNL must assume guardianship for the nursing
profession.
HEALTH CARE SYSTEMS
AND ORGANIZATIONS
• Systems theory
• Traditional organizational theory
• Hierarchy
• Scientific management
• Traditional role of nursing in health care system
• New theories to attend to growing complexities of
health care system
System Levels
Example
Frontline
Patient
Care
Units
Microsystem
Nursing
Divisions
Mesosystem
Nursing
Services
Macrosystem
Source: Henriks, Bojestig, Jonkoping CC Sweden
Key functions as a
leader in the CNL Role
• Horizontal leadership
• Effective use (and knowledge) of self in
caring and facilitating change for patients
• Advocacy
• Conceptual analysis of CNL role
• Lateral integration of care for a unit of
care/population
Leadership
• Leadership practice at the microsystems level
• Leadership vs. Management
• Leadership theories:
•
•
•
•
•
•
Great Man
Situational
Leadership style
Servant leadership
Transformational leadership
Complexity science leadership
New ORG Theories for
health care system
• Learning organization theory
• Chaos theory
• Complexity science theory
• Change theories:
• Lewin’s force field
• Roger’s - Diffusion of innovation model
• Complexity science – strange attractor
• New role for a new organization: CNL
• The Clinical Nurse Leader is the frontline change agent in
health care organizations
ORG THEORIES for Health
care systems
Learning organizations
• Organizations are living and thinking
open systems that learn from experience
and engage in complex mental
processes.
Theorist: Peter Senge
The Learning Organization
• Adaptive (single-loop) Learning
• Involves coping with a situation
• Limited by the scope of current organizational assumptions
• Occurs when a mismatch between action and outcome is
corrected without changing the underlying values of the system
that enabled the mismatch.
• Generative (double-loop) Learning
• Moves from COPING to CREATING an improved
organizational reality
• Necessary for eventual survival of the organization
• Both are central features to the learning organization
• Synergy and nonsummativity are Important
The Learning Organization
• Through communication, teams are able to
learn more than individuals operating alone.
• Leadership is a key element in creating and
sustaining a learning organization.
• Leaders are responsible for promoting an
atmosphere conducive to learning
• CREATIVE TENSION
New Directions in Org
theories for health care
Chaos theory
• Every complex system has a life of its own, with its own
rule book.
• Change is normal – chaos is part of change – look for
the patterns that emerge out of the chaos
• Fractals
Theorists: Fritjof Capra
New Directions in Systems
Thinking
Organizations as Complex Adaptive Systems aka
Complexity Science Theory – Leadership and the New
Science (Wheatley, 2006).
• Organizations are adaptive, living organisms with a life of their own
• Not predictable yet adaptable
• Complex systems are self-organizing.
• Small changes can have big effects
• Relationships are all there is
• Information is the life force of any organization
• It is normal for organizations to grow, die and reinvent themselves
• A static organization is a “dead” organization
Lewin’s change theory
 Force Field Analysis
 Begin change by analyzing the
entire system in order to identify
the forces for and against the
change: driving & restraining
forces
 Need to add driving forces or
remove restraining forces
 Change Model
 Unfreezing
 Change
 Refreezing
(Lewin, 1951)
Rogers’ (1995)
Diffusion of Innovation
Stages of adoption:
Awareness - the individual is exposed to the
innovation but lacks complete information about it
Interest - the individual becomes interested in the
new idea and seeks additional information about it
Evaluation - individual mentally applies the
innovation to his present and anticipated future
situation, and then decides whether or not to try it
Trial - the individual makes full use of the innovation
Adoption - the individual decides to continue the full
use of the innovation
Roger’s Diffusion of
Innovation Model
Positive Deviance
• Identifies change process by looking at the solution
first then designing the change process around success
•
•
•
•
Define
Determine
Discover
Design
• Answers the question:
• What enables some members of the community (the
“Positive Deviants”) to find better solutions to pervasive
problems than their neighbors who have access to the
same resources?
Traditional vs PD Problem Solving Approach
Flows from problem analysis
towards solution
Flows from identification
and analysis of successful
solution to problem solving
Fixed
Solution
Space
Perceived Problem Parameters
PD
Perceived Problem Parameters
Traditional
Perceived Problem Parameters
Actual Problem
Actual Problem
Parameters
Parameters
Expanded Solution
Space
Actual Problem
Parameters
why focus on the
“clinical microsystem?”
• Basic “building block” of health
care as a system.
• Where “good value” and “safe”
care are made.
• Unit of clinical policy-in-use.
• Where most health professional
“formation” occurs after initial
preparation.
• Locus of most workplace
“motivators” and many
“demotivators”
• It’s the front line
• Most variables relevant to patient
satisfaction controlled here.
• It’s where everything happens
with, to and for the patient and
family
20
The CNL Can assess the Clinical
Micro-system with the “5 Ps”
• Purpose
• Patients
• Professionals
• Processes
• Patterns
Nelson, Splaine, Godfrey,
et al, JQI, Dec. 2000.
21
HEALTH CARE QUALITY
& Patient safety
• Institute for Healthcare Improvement (2004) Patient
Safety Initiative
• Apply methods and tools of industrial quality
improvement
• Process improvement and team problem solving
Quality
• Must be defined & measured
• Is a moving target - must always be current
• Provides a competitive edge
• Doing things “right” the first time
• Focus on results - outcomes
• Must be strongly embedded in culture
• Must be linked to costs
Quality Improvement
 IOM Report (Crossing the Quality Chasm) recommends six
dimensions as potential themes for quality improvement:
1. Safety
2. Effectiveness
3. Patient-centeredness
4. Timeliness
5. Efficiency
6. Equity
Quality improvement
Tools and Techniques
•
PDCA
• Plan-Do-Check-Act
• Plan-Do-Study-Act (Deming, 1993)
•
Other Problem-solving tools
• Process mapping
• Flow charts
• Check sheets
• Pareto analysis
• Cause and effect diagrams
•
PDSA
• Objective
• Questions and
predictions (why)
• Plan to carry out the
cycle (who, what, where
, when)
•What changes are to
be made?
•Next cycle?
ACT
STUDY
•Complete the analysis
of the data
•Compare the data to
predictions
•Summarize what was
learned
PLAN
DO
•Carry out the plan
•Document problems
and unexpected
observations
•Begin analysis of the
data
AONE: Core Patient Safety
Technology Competencies
• Systems: Process management & process improvement
• Human factors
• Failure Mode Effects Analysis/Root cause analysis
• Safety rounding
• Teaming
• Risk management
Failure mode effects
analysis (FMEA)
• FMEA purpose: Eliminate or reduce
failures/harm
• Failure mode – manner in which failure occurs
and is observed
• Failure effect – consequences of failure
(prioritized by severity)
• Root cause analysis
• Common cause analysis
When Solving
Problems…
• Focus on prevention, not blame
• Realize a cause never stands alone
• A problem description is not analysis
• Start analysis with an impact to the goals not the causes
• Apply the basics of cause and effect, avoid buzzwords
• Analyze all - not only problems but success to determine cause
and effect
(Galley, 2007)
Client centered practice is
intra- and inter-disciplinary
• Effective communication skills – listen, listen, listen
• Team coordination and collaboration
•
•
•
•
•
Delegation and supervision
Interdisciplinary care and roles of the health care team
Group process
Handling difficult people
Conflict Resolution
• Leadership is all about communication
Social justice
• An essential value for the CNL
• Demonstrated through compassion, cultural
competence, patient advocacy and an understanding of
health disparities
• Support that health is a “right” not a “privilege”
CNL is the Guardian of
the Nursing profession
• CNL role is helping professional nursing to evolve to a
higher level of maturity and complexity
• CNL role helps to maintain focus of all activities on
patients and their well-being/safety
• CNL role continues to demonstrate that nursing is
more than just a job – it’s a vocation
• CNL role exemplifies the responsibility of knowledge
workers in an information society
References
• American Association of Colleges of Nursing (2007). White paper on
education and the role of the Clinical Nurse Leader. Washington, DC:
American Association of Colleges of Nursing.
• Institute of Medicine (2000). To err is human: Building a safer health system.
Washington, DC: National Academy Press.
• Institute of Medicine (2001). Crossing the quality chasm: A new health system
for the 21st century. Washington, DC. National Academy Press.
• Nelson, E. C., Batalden, P. B. & Godfrey, M. M. (2007). Quality by
design: A clinical Microsystems approach. San Francisco: Jossey-Bass.
• Wheatley, M. (2006). Leadership and the new science: Discovering order in a
chaotic world 3rd ed. San Francisco: Berrett-Koehler.