leadership in nursing

JONA: The Journal of Nursing Administration Issue: Volume 29(12), December 1999, pp 17-21 Copyright: © 1999 Lippincott Williams & Wilkins, Inc. Publication Type: [Articles] ISSN: 0002-0443 Accession: 00005110-199912000-00005 [Articles] Achieving Results Through Transformational Leadership Dixon, Diane L. EdD Author Information Diane L. Dixon, EdD, e-mail: [email protected], Principal, D. Dixon & Associates, Columbia, Maryland.

Outline

o Abstract o Building Relationships o Creating a Shared Vision for the Future o Developing a Strategy for Implementing the Vision o Recognizing the Value of Teamwork o Developing A Physician Integration Strategy o Communicating and Sharing Experiences o Creating a Learning Organization o Recognizing Results Achieved o Transformational Characteristics of the Leader o Summary o References

Abstract Transformational leaders must balance capable management with transformational skills that create shared vision, inspire others to embrace it, and empower them to lead implementation efforts. This balancing act requires leaders to be grounded in their personal values, live a balanced life, and continuously learn. A case example demonstrates how a former nurse executive, now a chief operating officer of one of the nation's top 100 integrated health systems, puts these concepts into action.

Healthcare is experiencing frame-breaking change and discontinuity leading to a fundamental shift in the way in which patient care is delivered. The new paradigm is not clearly defined nor agreed on, thus creating tremendous turbulence in healthcare organizations. Leaders are challenged to figure out the best methods for achieving operational results, creating shared

vision, and keeping staff motivated in unstable environments. In essence, they must balance the so-called hard issues of revenues and profit with the soft issues of human relations that include staff, customers, suppliers, boards, and other stake-holders. Maintaining a sense of stability in unstable environments is the mantra of 21st century leadership. Finding the right balance to maintain stability requires a dramatic culture change for most organizations, an entirely different way of doing business that is complex and fraught with paradoxes. Healthcare leaders must transform themselves before they can transform their organizations. Key to this metamorphosis is leaders' ability to embrace and put into action transformational leadership behaviors and characteristics. An essential element of transformational leadership is motivating and developing staff members and other key stakeholders so that they "perform beyond expectations"1(p2) to achieve a shared vision. The stakeholders are empowered to become leaders and build a culture that supports the vision. Sashkin 2(p15) suggests that culture building is essential to transformational leadership. At the heart of culture building is a clear understanding of organizational values and core purpose. Leaders must possess the ability to help all organizational players commit to what the organization stands for and how work is conducted. This is the foundation of change. Without this, transformation is doomed to failure. Other key behaviors include meaningful clear, consistent communication through multiple forms; acting with integrity and being authentic; and treating people with respect and dignity. These behaviors engender the trust building so central to teamwork. Finally, creating opportunities for innovation and risk taking provides the fuel that propels the organization to a new level of effectiveness. Capable management means that systems, processes, structures, and strategies support the vision and basic operations of the healthcare enterprise. Expectations are articulated clearly, and performance is monitored and rewarded. Leadership actions lead to the achievement of organizational and staff performance. The ability to balance transformational leadership and capable management requires the leader to live a balanced life (attending to mind, body, and spirit with the same zeal as restructuring the health system). Another very important component for balance is engaging in continuous learning. Openness to personal learning and facilitating the learning of others is a significant aspect of growth, change, and, ultimately, transformation. An excellent case example of the transformational leadership concepts just described is the work of a former nurse executive who is presently the chief operating officer (COO) of one the top 100 integrated health systems in the United States. The system is composed of five hospitals, urgent care centers, behavioral services, home health, assisted living, and long-term care with revenues in excess of $1 billion. At the beginning of this leader's tenure, one of the key tasks was to lead a cultural transformation in the system's flagship hospital as well as assist with the continuing growth and evolution of the entire health system. Like many hospitals and emerging health systems during the early 90s, the culture could be described best as traditional, hierarchical, command and control, and male dominated at the senior leadership levels. This leader's style was dramatically different from what most of the staff as well as some of the other leaders within the system had experienced.

The COO's first year in the system was spent trying to make sense of the resistance and yet create a vision for a better future. The methods by which she did it has many lessons for nurse executives in their current practice as well as for those who aspire to become top executives in healthcare organizations. Following are strategies that she used to set the transformation in motion. Building Relationships The first strategy was to simultaneously learn the organization and build relationships with staff and physicians. This was accomplished in a variety of ways not often typical of a top executive. Visibility was key. Rounds were made on all shifts, often to the surprise and delight of the front- line staff. She listened to concerns and observed issues first hand. Her clinical experience became an asset and enhanced the ability to fully grasp the struggles that staff members and physicians faced. Although the clinical background helped her gain credibility, sincerity and authenticity were the real trust builders. In a recent interview, the COO stated, "I have a strong belief in people; they want to do the right thing. I see in people what they do not see in themselves. I believe that I cannot do it all." This leader clearly recognizes the power of people and most importantly, is able to act on her beliefs. Creating a Shared Vision for the Future With the assistance of external organizational development consultants, an innovative approach was used to create a shared vision and begin participative decision making. Future Search is a values-based methodology developed by Weisbord and Janoff 3(p1) to help organizations create a shared vision by bringing the "whole system" into the room. The typical process involves reviewing the past and focusing on the present before ideal future scenarios are developed. Key to the process is the confirmation of "common ground." Once common ground is achieved, action planning begins. This is accomplished through full and simultaneous involvement of all stakeholders. The Future Search Conference and a series of cascading conferences included all levels of staff, physicians, and the community in the large group sessions. Cascading conferences were mini versions of the original Future Search Conference. The decision to use this participative approach was a dramatic departure from the past and pivoted the system in a new direction. These conferences not only resulted in a shared vision for the health system, but they were the beginning of enhanced teamwork and major transformation. Developing a Strategy for Implementing the Vision The high involvement cascading conferences were central to developing a strategy for implementing the vision. They focused on key change components such as culture, clinical services, human services, and technology. Internal leaders were developed to work with the external consulting team to facilitate the sessions. The end result was a concrete plan for implementing outcomes-based, patient-centered care throughout the health system. Central to the overall change process was the development of shared values and beliefs to support the vision. The system reached consensus on five core values. Called the "Culture Five," they are:

o Expert resources, o Conscientiousness, o Will-do attitude, o Sensitivity to the internal and external customer needs, and o Creative thinking.

The COO said, "Our challenge is to so consistently display those traits that they become our culture." Shared values and beliefs are essential to the cultural transformation process. Recognizing the Value of Teamwork In many healthcare organizations, individual or departmental excellence are the hallmark of success. The COO knew the vision would not become a reality without teamwork. She wanted to remove the silos and minimize barriers to working across all levels and functions in the system. These comments made by the COO characterize her values about the importance of teamwork: "Individually, everybody brings strength and expertise to the team. Nobody brings everything the team needs. But collectively, we have more than what the team needs." These team values were demonstrated when multiple multidisciplinary patient care re-design teams were established to implement the new strategy on a unit-by-unit basis. The patient care re-design teams include nurses, physicians, ancillary staff, and support staff working together to make the necessary decisions about how to deliver and improve quality patient care. Developing A Physician Integration Strategy Physicians were made key team players in this transformation process. The COO stated in an in- house physician newsletter that "Both an increased and more effective collaboration with physicians is integral to our future success as a healthcare system." To accomplish this goal, the Physician Strategy Initiative was launched. It is a large-scale planning effort made up of 17 physicians recommended by the president of each of the medical staffs and selected using specific leadership criteria. The physician work group collaborates with management to develop and design a strategic approach to partnering efforts. Examples of major areas of focus include: alignment through economic integration, engaging physicians in performance improvement, service line comanagement with the physician as "customer" to achieve superior quality, and a care management institute. The physicians in this health system have become real participants in the change process. In addition to the Physician Strategy Initiative, physicians participate in monthly breakfasts, system and hospital boards and councils, one-on-one meetings with executives, and various other organizational activities. These efforts are improving communication and increasing their input into decision making. As this case's leader stated in another physician newsletter article, "Commitment, collaboration, and communication are characteristics of successful partnerships."

Communicating and Sharing Experiences Communication is a critical element for this change effort. To increase communication in the system's flagship hospital, the COO created a monthly employee newsletter. She began writing columns that became not only vehicles for sharing general information but were a way to highlight milestones in the cultural transformation. Themes have included recognition for achievement of accomplishments, encouragement to forge ahead in tough and turbulent times, reinforcement of values and expectations, and operational results. The newsletters are not just top-down vehicles of communication; everyone is encouraged to contribute. In addition, there are voluminous reports, updates, and other forms of written communication to keep everyone informed. Sharing information is only one part of the communication equation. An open-door policy gives executives many opportunities to listen and engage in dialogue with all employees at all levels. For example, top executives have regularly scheduled office hours and do rounds so that employees have a chance to ask questions and discuss issues directly. These are also opportunities to show empathy and appreciation for the struggles that staff members must deal with daily to deliver quality care in the midst of change. Informal chats are important, too, and leaders throughout the system are encouraged to listen and be responsive to the staff. In this system, communication is more than words. It is a real commitment to sharing, listening, caring, and acting. Creating a Learning Organization The Learning Network was established to provide education, training, and development services throughout the health system. The network has the task of creating and helping to embed the culture foundation. In addition to the "Culture Five," there are four key culture elements:

o Accountability, o Partnership, o Commitment to service, and o Commitment to learning.

Culture foundation classes help lay the groundwork for understanding the new culture. The classes are another way to reinforce commitment to the shared vision and values. Classes include "Change Is Here to Stay"; "The Challenges of Customer Service"; and "The Fundamentals of Partnership." It is important to note that a true learning organization is not just training classes. The Learning Network is a catalyst for helping everyone to recognize learning opportunities in the daily work, including the mistakes inherent in rapid change. Creating an environment in which learning in action is both acknowledged and valued is a key goal.

Recognizing Results Achieved The COO in this case is astute in understanding that transformation without results and capable management causes failure. Throughout this change process, the focus has been on outcomes. Since the process began, the inpatient and outpatient satisfaction scores for the flagship hospital as well as the other hospitals in the system have risen to the 90th percentile based on organizational scores of "very good" or "excellent." Employee satisfaction scores rank above the norm in most indicators. Physician satisfaction is on an upward spiral as well. The teamwork that has been the linchpin of the health system's change efforts resulted in $27.8 million in savings because of ideas generated by the target-setting teams in 1997, for example. Patient care redesign is not only enhancing system integration and culture change; it is targeted to yield substantial savings in the millions. The progress report on patient care redesign, to date, is very promising. In fact, the president of the health system stated in an in-house newsletter that "[Patient care redesign] . . . is truly the work, consensus, and common ground of the system." This is a significant indication that patient care redesign is not just another change program but a real transformation. Transformational Characteristics of the Leader The strategies described are an excellent example of transformational leadership in action, but they are only part of the story. In studying leadership, one must examine the person. The leader in this example demonstrates what it takes. First, she has the ability to stay focused, indicating clarity about personal values and beliefs. It is this clearness that sustains the leader in tough and turbulent times. Another aspect of remaining focused that makes this leader successful is understanding that vision and outcomes are simultaneous imperatives. The leader continuously focuses on both. Clarity and consistency of beliefs and action are critical to leading in unstable times. Related to focus and equally as important is living a balanced life. A key aspect of this is managing multiple roles concurrently. In this leader's case, it means COO of the health system, wife, and mother. She indicates that by not seeing herself in compartments but rather as a whole person with different roles makes this possible. Further, this leader's approach is to be clear about outcomes and determine the priorities. The recognition that the help and talent of significant others including staff, peers, mentors, the boss, and family are important components to the balance. Hence, the foundation for managing multiplicity seems to be having adequate support systems and continuously assessing what is important at any given time with a clear focus on the whole. Another aspect of living a balanced life is self-management. This means attending to mind, body, and spirit with the same intensity as achieving organizational outcomes. In high-stress environments, it is easy to forget that mental and physical health are critical to survival and effective leadership. This COO indicates that positive stress, such as increased adrenaline from high achievement motivation helps keep the energy and passion for achieving vision and outcomes high. Conversely, negative stress such as overactivity and exhaustion can minimize energy and passion. She credits a healthy sense of humor and an ability to not take things too

seriously as being helpful for building resiliency. Also, recognizing that sometimes control comes from giving up control plays a considerable role in self-management. Central to success is continuous learning. In this case, the COO credits her ability to being open to learning as a critical factor. She believes that asking the right questions is more important than having all the answers. Listening and dialogue with staff are valuable sources of learning. In addition, reading, seeking advice and counsel from experts, attending conferences and educational events, and participating actively in professional organizations are just a few examples of this leader's self-directed learning efforts. Finally, the leader's willingness to admit mistakes and learn from them have been a powerful source of personal growth and enhanced her leadership ability. Summary The future of healthcare leadership rests in the ability of leaders to transform organizations to meet the complex demands of the 21st century. To accomplish this, leaders must become transformational. This means a shared, collaborative leadership approach that spans all boundaries to achieve outcomes. It requires the ability to build effective relationships while simultaneously focusing on results. Transformational leaders must manage the balance. The balancing act is challenging and sometimes even daunting but is the essence of successful leadership. Balancing multiple demands in increasingly turbulent environments is at the heart of creating healthier healthcare organizations that ultimately provide the quality of care that patients, families, and communities deserve. References 1. Bass BM, Avolio BJ, eds. Improving Organizational Effectiveness Through Transformational Leadership. Thousand Oaks, CA: Sage Publications; 1994. 2. Sashkin M. Transformational Leadership: A Review and Synthesis [working paper]. Ashburn, VA: The George Washington University, Institute for the Study of Learning; 1995. 3. Weisbord MR, Janoff S. Future Search: An Action Guide to Finding Common Ground in Organizations and Communities. San Francisco, CA: Berrett-Koehler Publishers; 1995.