Discussion 8

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Health Care Reform, Care Coordination, and Transformational Leadership

Robin Lea Steaban, MSN, RN, NEA-BC

This article is meant to spur debate on the role of the professional nurse in care coordination as well as the role of nursing leaders for defining and leading to a future state. This work highlights the opportunity and benefits associated with transformation of professional nursing practice in response to the mandates of the Affordable Care Act of 2010. An understanding of core concepts and the work of care coordination are used to propose a model of care coordination based on the population health pyramid. This maximizes the roles of nurses across the continuum as transformational leaders in the patient/family and nursing relationship. The author explores the role of the nurse in a transactional versus transformational relationship with patients, leading to actualization of the nurse in care coordination. Focusing on the role of the nurse leader, the challenges and necessary actions for optimization of the professional nurse role are explored, using principles of transformational leadership. Key words: bundle payments, care coordination, health care reform, top of license, transformational leadership

THE IMPERATIVE

No matter what the role of a nursing leader in an organization, the stewardship of the profession of nursing should be an ever present concern. Health care reform efforts and the progressive implementation of the 2010 Affordable Care Act have created an opportunity for nurse leaders to advance the profession and actualize the full potential of professional nurses. Nursing leaders and others have long talked about nurses working to the top of their licenses. Health care reform creates the burning platform to do just that.

Author Affiliation: Vanderbilt University Hospital and Adult Clinics, Vanderbilt University Medical Center, Nashville, Tennessee.

The author declares no conflict of interest.

Correspondence: Robin Lea Steaban, MSN, RN, NEA- BC, Vanderbilt University Hospital and Adult Clin- ics, Vanderbilt University Medical Center, 1301 Med- ical Center Dr, Ste 3601 TVC, Nashville, TN 37232 ([email protected]).

DOI: 10.1097/NAQ.0000000000000158

The Accountable Care Act provides a vision for the provision of this country’s health care. Simply stated, that vision is to add value. The directive is to improve or sustain quality while decreasing costs of care. The Centers for Medi- care & Medicaid Services recognizes that the current fee-for-service payment model has in- creased the delivery of fragmented and unnec- essary care and not rewarded coordination of care across multiple settings and providers. In addition, Medicare and Medicaid have tradi- tionally not recognized or rewarded providers of care for quality of care or reliable outcomes through the payment system. With a new focus on care coordination across the con- tinuum, sustaining or increasing quality, and decreasing costs, Medicare is shifting from fee for service to shared savings and at-risk payments associated with both Accountable Care Organizations and bundled or episode of care payments. This article relates pri- marily to transformation associated with the care coordination necessary for health care system financial survival when payment is based on acute episodes of care or bundled payments.

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To this point, most participation in bundled payment reimbursement or episode-based care initiatives has been voluntary. The most notable voluntary episode of care project has been the Medicare Bundle Payment Care Im- provement Project. Today, the landscape is quickly changing from voluntary to mandated participation, as Centers for Medicare & Med- icaid Services announced its commitment to shift 50% of Medicare payments to alternate methodologies such as Accountable Care Or- ganizations and bundled care by 2018.1 An early sign of this commitment is the require- ment for 75 metropolitan statistical areas in the country to move to bundled payment par- ticipation in the Comprehensive Care for Joint Replacement Model in 2016. In some states, such as Tennessee and Arkansas, Medicaid programs are transitioning to a bundled reim- bursement system over a number of months and years. In Tennessee, commercial payers who cover state employees are required to of- fer bundled reimbursement as well. This is drastically changing the obligation of tradi- tional acute care health systems from finan- cial risk associated with the acute event to financial risk from acute admission through full recovery extending 30, 60, or 90 days postdischarge.

Medicare is also testing a change to bun- dled reimbursement for high-risk, high-cost outpatient care. Voluntary participation in the Oncology Care Model shifts payment for pa- tients receiving chemotherapy to bundled re- imbursement for participating organizations in 2016. In addition, the change to pay for performance and value-based purchasing puts health care systems at risk for meeting nation- ally defined process and outcome standards of care. These changes begin to align the provi- sion of national health care with the Institute of Medicine (IOM) recommendations of safe, timely, effective, efficient, patient-centered, and equitable care across the continuum of health and wellness.

The Health Care Reform mandate to man- age patients to the best possible outcome at the lowest cost creates a burning platform for nursing leaders to examine the role of

the nurse and to maximize nurses’ contribu- tions to the value equation. The IOM report on the future of nursing2 clearly delineates the need to remove practice barriers for advanced practice in support of quality outcomes and safe patient care. The second recommenda- tion of the report is to expand opportunities for nurses to

• lead and diffuse collaborative improve- ment efforts with physicians and other members of the health care team to conduct research and redesign and im- prove practice environments and health systems;

• lead in developing and adopting innova- tive, patient-centered care models that use nurses in an expanded capacity to im- prove health outcomes and reduce costs, where best practices are evident, reflect the contributions of nurses, and ensure better-quality care; and

• contribute to improved health and health care.

The IOM Report encourages maximizing the contributions of nurses at a time when nursing leaders are faced with an increased demand for nurses. In addition, nurses con- tinue to leave their jobs and the profession. Controllable reasons nurses leave their jobs, as reported by Gardulf et al,3 include lower quality of patient care (P < .01) and nurses’ perception that their competence is not be- ing put to good use (P < .001). An activity- based costing approach used by Storfjell et al4 reports that more than one-third of nurses’ time was considered non–value added, which is consistent with nurse per- ceptions that they are not making good use of their competence. In their 2008 activity- based study, Storfjell et al4 found added wage costs associated with non–value-added time spent by nurses translated into $726 000 to $1 084 000 per unit depending on the unit type. Data were collected from 14 medical surgical units, 2 intensive care units, and 3 la- bor and delivery units from 3 hospitals in Mid- west United States. If that time was translated into professional practice time, the pursuit of value in health care might be advanced.

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Health Care Reform, Care Coordination, and Transformational Leadership 155

Health care reform, the IOM report, the sat- isfaction of nurses, their intention to stay in the profession, and the economics of health care all demand that nursing leaders address the role of the professional nurse and top of license contributions. If nursing leaders use mandates of health care reform and respond in a way that maximize the competence and capability of every nurse, they will be able to meet the requirements of creating value for patients and payers, while creating profes- sionally satisfying roles. Nursing leaders must not miss this opportunity to transform prac- tice of nurses in hospitals and clinics across the nation.

CARE COORDINATION

Until recently, bundled care efforts have not mandated the methods used by health care organizations and providers to improve value. Standards have now been set for qual- ity performance metrics in bundles as well as payment. This bundled approach consid- ers care across the continuum. The “how” of getting to established goals has largely been left to researchers, health care organi- zations, and physicians. Medicare Bundle Pay- ment Care Improvement Project participat- ing organizations have been allowed to define their interventions. These often include care coordination. Almost every revised model of care, whether focused on reducing penalties for readmissions, mitigating financial risk, or meeting gain-sharing benchmarks in bundled payment models, has included care coordina- tion. In the Oncology Bundle project, Medi- care now requires care coordination for pa- tients enrolled in the bundle.

The literature is replete with studies report- ing the approach and impact of care coordi- nation models. There is little standardization in model designs or definition of care coordi- nation between one system and another. The results are mixed in terms of evidence that care coordination reliably improves health outcomes while reducing costs. Many systems have responded to the need for greater care

coordination across multiple settings, various disciplines, and the continuum of care. They have done this by layering a new job of a care coordinator (in the form of another person) on top of nursing roles that are already in- volved in caring for and managing patients. Payers also have layered in nurse and non– nurse care coordinators to mitigate high costs of caring for patients with increased health risks. While there have been some successes, there also has been confusion about who and how many people it takes to coordinate care. The New York Times recently highlighted the problem of multiple care coordinators being involved in a single patient’s care, and asked, “Who is coordinating the care coordinators?”5

The Agency for Healthcare Research and Quality defines care coordination as

The deliberate organization of patient care activi- ties and sharing of information among all of the par- ticipants concerned with a patient’s care to achieve safer and more effective care. This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.6(p59)

In the book Care Coordination: The Game Changer, the author proposes that care co- ordination falls into 2 categories.7 The first is care coordination associated with transi- tions of care such as movement from an acute care setting to home. The second is compre- hensive care coordination for chronic and/or complex conditions over time that may or may not include a transition from one health setting to another. Author G. Lamb compre- hensively reviews the literature and provides a framework of the common components of care coordination models in both transitions and comprehensive care coordination. Those components include

• targeting those patients who need and would benefit most from care coordina- tion;

• providing care through engagement of multidisciplinary teams, with RNs man- aging and delivering most interventions,

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supported by and collaborating with other team members such as social work- ers, rehabilitation specialists, community care workers, and navigators;

• collaborating closely with the primary care provider and/or the specialist pro- viding care for the patient;

• documenting and accessing patient- specific information through an inte- grated information system; and

• relying on an understanding of patient outcomes to inform the learning needs of team members.

Lamb7 describes the tasks of a care coordi- nator as

• developing a collaborative relationships with multidisciplinary team members;

• developing an individualized care plan with the team;

• setting goals and prioritizing care with the patient and family;

• educating and coaching patients and families/caregivers for successful self- care;

• coordinating and evaluating care pro- vided by others;

• evaluating care, updating the team, and adjusting the plan of care as needed; and

• facilitating communication between the patient/family and all providers during times of transition.

Professional nurses working in inpatient environments such as hospitals and those who work in outpatient settings such as physi- cian office practices and clinics are positioned well to provide care coordination. To inpa- tient staff nurses (SNs) and outpatient practice nurses (PNs), the common components and tasks identified look very familiar. They de- scribe the competencies and the desired roles of the professional nurse. Perhaps these com- mon components describe the competencies that nurses believe they are not able to use.3

The question before every nurse leader in to- day’s environment is how and who will pro- vide care coordination for patients. Many au- thors have focused on the opportunity that the Patient Protection and Affordable Care Act offers for the expansion of nurse practitioners

in primary care. There is, however, another and perhaps more challenging imperative for nursing leaders. That challenge is to step into the opportunity for all nurses to work at the top of their licenses, fully use their competen- cies, and experience satisfying jobs. The ques- tions posed are as follows: (1) Can and should the role of the inpatient SN and outpatient PN be leveraged to maximize the care coordi- nation functions that are legitimately part of professional practice to improve value of care, and (2) Can it be done in a way that creates a satisfying role for nurses?

OPTIMIZING THE ROLE OF THE NURSE THROUGH CONSIDERATION OF A CARE COORDINATION MODEL

The Advisory Board8 and others have fo- cused on “targeting” patient populations to identify the need for care coordination, as noted by Lamb7 and others. The population health pyramid demonstrates the predicted distribution of a population that ranges from healthy to in need of complex interventions and the characteristics of patients at each level. This pyramid is a useful model to think about, when considering “who” will coordi- nate care. It is the suggestion of this author that everyone needs care coordination but not everyone needs a care coordinator (Figure 1).

The author of this article proposes a model of who might coordinate care at each level of the Advisory Board’s pyramid. If inpa- tient SNs and outpatient PNs work to the top of their licenses, their practice is consis- tent with the roles of care coordination de- scribed by Lamb.7 The proposal is that for the “healthy patient” population, SNs and PNs are well suited to meet the needs of transitions of care from inpatient to outpatient status, health maintenance and acute illness educa- tion, surveillance, evaluation, and escalation for a new plan of care (Figure 2).

As patients move up the pyramid, their care becomes more complex and in need of more diverse professional and unlicensed support. At this point, they may require professional skills and expertise extending beyond the

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Figure 1. Population Health Pyramid demonstrates the distribution of patients in the population and the health characteristics of patients at each level of complexity. Adopted with permission from Advisory Board. https://www.advisory.com/research/health-plan-advisory-council/members/events/ webconferences/2014/prioritizing-population-health-interventions. C©2014 The Advisory Board Com- pany (ABC). All rights reserved. Author further acknowledges that ABC does not sponsor, endorse, pro- mote, or otherwise support the Licensee’s published opinions. There is no relationship between Licensee and ABC other than Author’s employer Vanderbilt University has purchased memberships in ABC’s com- mercially available memberships.

capability or capacity of the staff and the PN. These advanced skills and expertise may in- clude advanced health coaching or knowl- edge of coordination of care across multiple systems and disciplines. The recommendation is that inpatient and PN efforts are supple- mented by case managers in inpatient envi- ronments and medical home care coordina- tors for the “at-risk” patients in the outpatient environment. The “at-risk” hospitalized pa- tients may receive service from multiple con- sultants. They may also require more intense post–acute care, closer surveillance, and fre- quent post–acute care interventions for a new diagnosis or uncontrolled chronic disease.

At the highest 2 levels of the pyramid, the most unstable, complex, medically and psy- chosocially challenged patients reside. Exam- ples of patients at these levels include patients experiencing organ transplantation, severe trauma, complex and high-risk surgical proce- dures (such as cardiac and neurosurgery), can- cer treatments, instability of aging (coupled with social support challenges), or environ-

mental or psychosocial deficits (coupled with health-related challenges). These patients require care coordination from experts who have a deep knowledge of their individual medical and psychosocial situations. The pa- tients at these levels are fragile. They require frequent communication with the health care system for monitoring, evaluation, coordina- tion of complex care needs, access to com- munity and health care resources, and appro- priate adjustments to the plan of care. These are patients who need a consistent care coor- dinator across the continuum. Patients move up and down the pyramid as their condition changes. The goal of care coordination is to migrate the patient downward in the pyramid to stable, higher levels of health and wellness.

STAFF AND PNS AS TRANSFORMATIONAL LEADERS

Transactional leadership and transforma- tional leadership are differentiated by Bass and Riggio9 in their work on leadership styles.

https://www.advisory.com/research/health-plan-advisory-council/members/events/webconferences/2014/prioritizing-population-health-interventions

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Figure 2. Proposal of the primary nursing role responsible for care coordination at various lev- els of patient complexity and for hospitalized patients as well as outpatients including a high level view the work of care coordination at each level. Adapted from Advisory Board Population Health Pyramid. https://www.advisory.com/research/health-plan-advisory-council/members/events/ webconferences/2014/prioritizing-population-health-interventions. C©2014 The Advisory Board Com- pany (ABC). All rights reserved. Author further acknowledges that ABC does not sponsor, endorse, pro- mote, or otherwise support the Licensee’s published opinions. There is no relationship between Licensee and ABC other than Author’s employer Vanderbilt University has purchased memberships in ABC’s com- mercially available memberships.

Transactional leadership is described as so- cial exchange where one thing is exchanged for another. Transformational leaders, in con- trast, are those who “stimulate and inspire others to achieve extraordinary outcomes” that exceed expected performance. They cre- ate high levels of satisfaction and commit- ment. Transformational leaders help others grow and develop by empowering them. They align goals and objectives of the individual, the group, the leader, and the organization. Bass and Riggio suggest that transformational leaders set goals with those they lead so that they can reach higher levels of performance.

Transformational leadership is not just the responsibility of the people at the top of an or- ganization but at every level. Nursing leaders need to use transactional leadership behav- iors to accomplish the work of the day. How- ever, they should also aspire to demonstration

of behaviors consistent with transformational leadership. Staff nurses and PNs can enter ei- ther into a transactional relationship with a patient and family or a transformational part- nership where every encounter helps those in the health care system understand the desires and capability of the patient and the family. Through this relationship, the nurse matches the goals for the health care team with the patient and family goals. Nurses need to see their roles as transformational where they help the patient and family achieve health and illness management at increasingly higher levels.

As noted earlier, some nurses feel that they do not use the full breadth of their com- petencies in patient care situations. Health care environments have sometimes reduced nursing practice to a series of transactional tasks. The Table provides a comparison of

https://www.advisory.com/research/health-plan-advisory-council/members/events/webconferences/2014/prioritizing-population-health-interventions

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Table 1. Work of the Inpatient Staff Nurse (SN) and the Outpatient Practice Nurse (PN) Viewed From a Transactional Versus Transformational Role Implementation

Work

Transactional RN and Patient Encounters (SN = Staff Nurse

(Inpatient Nurse; PN = Practice (Outpatient Nurse)

Transformational RN and Patient Encounters When Not Noted, Content Applies to SN and PN

Bathing/assisting patient with ADLs

SN: Cleansing the skin, oral care • Assessment of skin, motor function, self-care capability.

• Education on hygiene, wound care • Assessment of safety related to

performing self-care in the home environment

Medication management

SN: Medication administration— Telling patients what medication is and why they are taking it

PN: Renewal of prescription by protocol or MD order

Assessment of • Knowledge of medication purpose,

side effects, administration requirements

• Ability to self-administer medication according to the plan

• Reliability of medication self-management

• Intent/capability to comply with the medication plan of care

• Effectiveness and/ or side effects of medication

• Presence of poly pharmacy • Planning to mutually goal set with

patient, remove barriers to reliable medication management

Admission assessment or clinic intake

SN and PN: Data collection • Assessment of physical status with immediate needs identified

• Assessment of knowledge of disease condition or procedure

• Demonstration of self-care capability from former health care experiences.

• Environmental, psychosocial determinants of health

• Strengths/weaknesses of external support for health care needs

• Adherence to established plan of care

• Goals for visit/hospitalization and health and wellness

• Motivational interviewing—What do you want to accomplish for your health?

(continues)

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Table 1. Work of the Inpatient Staff Nurse (SN) and the Outpatient Practice Nurse (PN) Viewed From a Transactional Versus Transformational Role Implementation (Continued)

Work

Transactional RN and Patient Encounters (SN = Staff Nurse

(Inpatient Nurse; PN = Practice (Outpatient Nurse)

Transformational RN and Patient Encounters When Not Noted, Content Applies to SN and PN

Handover for transition of care

SN: Bedside report—exchange of information to assist the health care team receiving the patient (SBAR)

PN: Post–acute care report and interaction—exchange of information within and focused on knowledge of the health care team

• Interaction with the patent and family to set/reaffirm patient and family goals

• Validate accuracy of collected information and inferences from data

• Education of safety risks with mutual goal setting to prevent injury

• Negotiating and evaluating self-care activities

Discharge SN: Discharge—Provide information for necessary self-care after discharge r/t appointments, medication prescriptions, activity, and diet and condition-specific information

PN: Discharge phone call for those deemed high risk—Satisfaction-based call

SN • Teach back for understanding of

disease/condition • Validate patient has a precise plan

to get medications and knows what to do with meds at home

• Demonstration back on dressing changes, etc.

• Teach back on how to adhere to diet and activity restrictions

• Teach back on date, time of follow-up appointment

• Teach back on reason for postdischarge phone call and confirmation of correct phone number

• Teach back on when and how to access care if recovery is not progressing

PN • Assessment based on self-report of

condition and identification on any issue requiring escalation/ clarification, follow-up visit

• Compare patient report of meds taken in last 24 h to medical plan

• Use self-reported dietary intake to assess implementation of the plan of care and dietary restrictions

• Teach back on how to adhere to diet and activity restrictions

• Teach back on date, time of follow-up appointment, and confirmation of plan to attend visit

Abbreviations: ADLs, activities of daily living; RN, registered nurse; SN, staff nurse.

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transactional versus transformational ap- proaches to patient care viewed through the lens of both PNs in outpatient setting and SNs in inpatient setting.

It is time for nurses to understand and actu- alize their roles as transformational caregivers with a responsibility for coordination of care. It also is time for nursing leaders to manage the environment and create space, tools, and the conditions for nurses to live out their full potential as optimizers of conditions where those we care for are better supported in their quest for health and wellness.

THE CALL TO ACTION FOR NURSING LEADERS

Nursing leaders should not miss the current opportunity to transform the work of the pro- fessional nurse. It is time to develop models of nursing that expand nursing roles to achieve improved health outcomes and reduce costs. This author believes that the staff and PNs are wasted resources unless they work to the top of their licenses. Frontline nurses should coordinate care of patients. Leaders must de- velop, implement, and evaluate models of care as well as systems of care so that the nursing efforts are leveraged toward optimal health outcomes. The tiered care coordina- tion model described previously is one way to consider what might help nurse leaders tackle “top of license” performance for staff and PNs.

WHAT NEEDS TO BE DONE?

Creating and sustaining an environment where nurses work at the top of their ed- ucational and licensure capability has been a long-term frustration in the nursing profes- sion. Health care systems are imperfectly de- signed and engineered, and often the sharpest end of the health care system, the nurse, is found lacking supplies and resources neces- sary to provide care. This results in the non– value-added work for nurses as they spend time acquiring necessary resources. In spite of this, they consistently fill service and care

delivery gaps and are the last line of defense for patients and families. They are committed professionals who ensure that tasks related to patient care are accomplished. By perform- ing well with limited resources, nurses have carved a perception in the minds of others about their role, which minimizes recognition of their full capability and responsibility to contribute to improved patient outcomes.

The role of the nurse leader is critical if nurses are to provide care coordination across the continuum. Optimizing the contributions of the professional nurse calls for a change in nurses’ own perceptions and behaviors. It also requires transforming the perceptions of the health care team and the systems in which nurses work. Nonprofessional work must be redistributed, eliminated, and/or re- duced in frequency. Models of care must provide unlicensed staff to accomplish un- licensed work, build in role clarity and ac- countability for all team members, and po- sition nurses for successful encounters with patients and other health care professionals. Nurses will need to shift from a task orienta- tion with an increase of understanding their role in transformational care. This entails shift- ing nurses’ thinking beyond their immediate environment so that they consistently con- sider the next stage for patients as they transi- tion to the next level of care. This new world view will help shape the nurse as a transforma- tional provider. Comprehensively preparing the patient and family for what they will expe- rience at the next phase and what will be nec- essary for safe and effective self-care necessi- tates that nurses develop bigger picture view- points. Each nurse must accept the role of leader of team collaboration, no longer defer- ring to other professionals to fill the gap. The nurse must recognize when the situation ex- tends beyond his or her capability. He or she can then use knowledge, skill, commitment, and capacity to engage others who can as- sist the patient and family in reaching optimal outcomes.

Negotiation and education of the health care team regarding the potential of the nurse when fully deployed for the benefit of the

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patient occurs as the nurse leader demon- strates respect and understanding for the roles and contributions of other professionals.

Re-engineering nursing assistive roles will need to occur to leverage the nurse’s performance. Nurses must be accountable for consistently demonstrating their capability to lead and coordinate care. When this occurs, the mindset of the health care team can evolve on the basis of the demonstrated value of the professional nurse. The nurse leader must be prepared to quantify and demonstrate the impact of the changes in roles.

In his book, The Fifth Discipline, Peter Senge10 focuses on a learning organization. He describes the essentials of an organiza- tion being able to create its own future by creating it versus simply adapting to condi- tions that force change. Senge uses the word “Metanoia” to describe a “shift of mind” nec- essary for real learning. He describes learn- ing that gets to the heart of what it means to be human (and in this instance, this author suggests), what it means to be a nurse. Senge offers that one challenge of change is that indi- viduals often see themselves as their jobs and define themselves by the work they do. What we are asking each nurse to do is to practice at the top of his or her license by reinvent- ing the professional nurse role in relationship with other team members. This requires con- tributing differently, understanding how their own behavior inhibits their ability to get to the new reality, and changing their behavior. They also must understand how the decision to change roles starts a complicated cascade of events that affects the roles, responsibili- ties, and work of others.

TRANSFORMATIONAL LEADERSHIP APPLIED

There is much attention (including Magnet recognition), given to the requirement for transformational leadership. It is the premise of this author that the transformational leader does not transform the organization. Rather, the transformational leader creates an environment where those closest to the work

can unleash their creativity in response to challenges and opportunities. Transformation of organizations relies on the ability of people who do the work to envision the future, them- selves in it, and to change their own actions to get to the new vision. Bass and Riggio9

describe 4 concepts of transformational leadership: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration. Attention of these concepts provides a solid foundation for anchoring the leader to support the potential of nurses in their organization.

Willingness of staff and others to consider the migration of nurses’ roles to top of license performance is dependent on the trust and confidence staff and the organization have in the leader with vision. Idealized influence re- lates to what others see as the capability of and what they attribute. Chief nursing officers and other nurse leaders who have demonstrated capability to lead significant change in the past will more easily develop followership of staff and other leaders. These are chief nursing offi- cers and other leaders are seen as consistently committed to doing “the right thing.” They are perceived as highly ethical, willing to take risks, determined, and persistent. They role model optimism and excitement about the future.

The requirements of health care reform are calling nurses to a new level of contribution. It is an exciting time for nurses. Leaders can help nurses and others see the possibilities and value in new roles and relationships. Nurs- ing leaders must raise hope and confidence in the hearts, minds, and intellect of nurses and others and help them imagine an attractive future state.

Intellectual stimulation results when those affected by the change are engaged in creating the new future. Leaders need to create space for staff to think about approaching problems with new solutions. They must provide opportunity for staff to learn new skills, such as coaching and motivational interviewing. Leaders must support development of staff confidence by providing opportunities for them to create and safely experiment with

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new models and systems. They must be safe to learn from failures and successes until a right, lasting, and scalable solution can be found. Rigorous metrics and the demonstra- tion of improved patient outcomes linked to the unleashed capability of nurses in new models will give staff confidence and courage to make significant and lasting change in their roles.

Nurse leaders must craft individualized interventions to attend to the needs of many participants in the system of care. Others must not only envision a different role for the nurse, but are creating their own capabilities to thrive in a system that promotes and protects the role of the nurse. Nurse leaders must meet others in the system where they educate and demonstrate value of the nurse, which demonstrate improved patient outcomes. They can then identify leading indicators for the professional nurse to prac- tice to the top of their licenses. By listening to the concerns and needs of others while managing the interdependencies that make a health care system effective and efficient, nurse leaders can potentiate optimization of the professional nurse role.

CONCLUSION

Health care reform is rapidly changing the landscape of the health care environ- ment. This requires proactive and anticipatory responses on the part of health care leaders. Transformational nurse leaders have the op- portunity to respond to the compelling need laid out by health care reform. They can add value for patients and families, while optimiz- ing the role of the professional nurse in tradi- tional settings.

Care coordination is seen by many as an essential part of delivering on the value equa- tion. The roles and responsibilities for this are currently being debated. Nursing leaders must participate in these discussions and view this as an opportunity to secure the professional role of the nurse. Leaders have the ability to drive solutions that preserve and optimize the role of the professional nurse as a transfor- mational provider of care. Through the appli- cation of transformational leadership princi- ples, nurses can drive the debate and create a satisfying work environment for nurses while meeting patient needs and the demands of health care reform.

REFERENCES

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