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Familiarity can be compromised by status or other differences that suppress interaction Goodman and Garber, ; Goodman and Leyden, As a result, people from different parts of the organization and different status levels often find it difficult to share knowledge. Such boundaries inhibit the flow of information; they keep individuals and groups isolated and reinforce preconceptions.

A solution to this problem is to break down boundaries and stimulate the exchange of ideas between individuals at multiple levels of the organization through formal and informal practices that bring people together for this purpose DeLong and Fahey, Conferences, meetings, and project teams that cut across organizational levels promote a fresh flow of ideas and the chance to consider competing perspectives Garvin, Providing time for thinking, learning, and training For knowledge to be created and adopted, employees must have sufficient time for reflection and analysis to assess current work systems and devise new work processes.

Such learning is difficult when employees are harried or rushed; it tends to be displaced by the pressures of the moment.

Developing High Performance Leaders

Only if top management explicitly frees up employee time for this purpose does learning occur with any regularity. Further, employees must posses the skills to use learning productively. To perform and evaluate experiments, managers and staff members need skills in such areas as statistical methods and experiment design in order to perform and evaluate experiments. These skills are seldom intuitive and must be learned. Such training is often most effective when intact work groups participate in the training together. Training in brainstorming, problem solving, evaluation of experiments, and other core learning skills is essential Garvin, All of the organizations managed according to the Toyota Production System, for example, share an overarching belief that people are the most significant corporate asset and that investments in their knowledge and skills are necessary to build competitiveness.

They invest heavily in training and in creating among coworkers shared understandings of problem solving and innovation processes Spear and Bowen, Organizations need to create formal programs or events with explicit learning goals in mind. Each of these activities fosters learning by requiring employees to grapple with new knowledge and consider its implications for the organization Garvin, Knowledge is more likely to be transferred effectively when the right incentives are in place Garvin, In a study of 31 knowledge management projects at 24 corporations, the motivation to create, share, and use knowledge was found to be a critical success factor for the projects.

The researchers concluded that incentives to contribute should be long-term and should be linked to both the general evaluation and compensation structure of the organization Davenport et al. Some organizations have used the extent to which employees contribute to the organization's knowledge repository as a component of employee evaluations and compensation decisions Davenport et al.

The U. Army is one of a growing number of organizations that formally consider knowledge-sharing capabilities when identifying candidates for promotion DeLong and Fahey, While some nurses have had firsthand experience with the successful application of the above evidence-based management practices in their workplace, this has not consistently been the case.

Concerns about changes in nursing leadership, increased emphasis on production efficiency in response to cost-containment pressures, weakened trust, poor change management, limited involvement in decision making pertaining to work design and work flow, and limited knowledge management are all found in nurses' work environments. Each of these barriers to the application of evidence-based management practices in nurses' work environments is discussed in turn below.

Nursing leadership in hospitals and other HCOs has a key role with respect to the deployment of the nurse workforce in these institutions and overall patient care. This role, however, at least in hospitals, is changing. Evidence suggests that these changes may diminish the ability of hospital nursing leadership to 1 represent nursing staff and management to each other and facilitate their mutual trust, 2 facilitate the input of direct-care nursing staff into decision making on the design of work processes and work flow, and 3 provide clinical leadership in support of knowledge acquisition and uptake by nursing staff.

The senior nurse leadership position in hospitals has not always been an executive-level position. A national Commission of Nursing report and publications of the American Hospital Association recommended to hospitals that chief nursing officers CNOs be regarded as a key component of a hospital's executive management team. Recommendations that nurses be involved in policy development and decision making throughout the organization were important in bringing the CNO position to the executive management team in many hospitals Clifford, This view of the CNO position is consistent with both old and new management concepts.

Florence Nightingale, the founder of modern nursing, made major improvements in the education and training of nurses in the latter part of the nineteenth century.

She proposed an administrative system for hospitals that included a triad of lay administrator, physician leader, and senior nursing leader. Her model was an important contributor to the development of hospital management systems and was responsible for the introduction of the position of superintendent of nurses to U. Nightingale asserted that only those trained as nurses were qualified to govern other nurses Clifford, This view also is consistent with the more recent management philosophy embodied in the Toyota Production System, which requires that all managers know how to perform the jobs of those they supervise Spear and Bowen, Until recently, the CNO was the official leader of a hospital's nursing staff.

Although other administrative responsibilities may have been involved, the primary role of the CNO was the administration and leadership of the nursing service Clifford, In the past two decades, the role of the CNO has continued to expand as a result of service integration and hospital reengineering initiatives.

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In surveys conducted in and of nurse leaders in VHA, Inc. Nearly all of these respondents identified expanded responsibilities as a major feature of their role change. The new, expanded roles of these hospital nurse leaders included responsibilities for radiology departments, surgery, emergency departments, cardiology, nursing homes, outpatient services, admitting, and infection control units Gelinas and Manthey, Even as CNOs have increasingly assumed these expanded managerial duties, they also have retained responsibility for managing nursing services.

Research is needed on whether the expanded role of the CNO has beneficial or adverse effects on patients Clifford, Some assert that expanding the CNO role increases senior nurse executives' influence in desirable ways. Others express concern that the expansion of the CNO's areas of responsibility beyond those directly associated with clinical nursing takes attention away from nursing care and hinders the development of strong nursing leadership for nursing practice in the hospital.

What is agreed upon is that as the roles of nurse leaders have expanded, so have the demands of balancing two, often competing, sets of responsibilities as senior administrative staff and leader of nursing staff.

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As senior executive, the CNO must help the hospital meet its strategic goals, which are often financially focused. As leader of nursing staff, the CNO is responsible for providing clinical leadership. Concern has also been expressed that the attempt to meet both sets of responsibilities has resulted in the potential loss of a common voice for nursing staff and a weakening of clinical leadership. Moreover, fewer nurse managers, directors, and assistant nurse managers were found at all levels of the hospitals Clifford, This phenomenon has been documented to occur on a more widespread basis.

In the previously cited and surveys of nurse leaders in VHA, Inc. HCOs and AONE nurse executives and managers, nearly one-third of all respondents indicated that after their redesign initiatives, there would no longer be a separate department of nursing Gelinas and Manthey, Hospital staff nurses further affirm these findings.

A more recent, — survey of nurses working in acute care hospitals in Pennsylvania additionally found that The potential loss of the ability of these nursing leaders to represent staff nurses is articulated in a report on the findings of interviews with executives of 13 VHA, Inc. HCOs conducted in The nurse authors of the report state:. It was not uncommon to find nursing personnel reporting to non-nurse administrators, and former nurse executives responsible for non-clinical, non-patient care departments….

Nurse executives are fulfilling a variety of roles previously considered strictly administrative, including those of chief operating officer and CEO. In this capacity, it is inappropriate for them to be spokespersons for the nursing profession within their institution—they must be spokespersons for the broad function of patient care.

Although this bodes well for improvements in patient care, it also dislocates the strongest voice for professional nursing issues. For the past 20 years or so, nurse executives have been spokespersons for the profession at the institutional, local, state, and national levels, both as individuals and through their organizations and associations.

Because of the dramatic role changes underway, the ability of this group to effectively represent the nursing profession may be seriously compromised. The nursing profession may be well-advised to find leaders from other settings—practice, education, or research. Gelinas and Manthey, Leadership for the clinical practice of nursing also has been identified as at risk.

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In the above-cited qualitative study of the changing role of hospital CNOs in three not-for-profit flagship hospitals, changes in the clinical leadership role of the CNO were found not to have kept pace with the growth and strength of the administrative responsibilities of that role. Similar changes were experienced down the line. The span of control of the midlevel director of nursing increased, and the incumbent had less time to spend with individual unit managers. Unit managers had less ready access to the midlevel director of nursing. They no longer had someone to whom they could readily turn to help them reflect on problems and issues requiring their attention.

Similarly, the nurse unit managers' span of control had increased. Some nurse managers were now responsible for more than one patient care unit as the number of nurse managers in these three hospitals decreased Clifford, These findings echo those of interviews with executives of 13 VHA, Inc.

HCOs beginning in These executives reported that in organizations that had retained a traditional nursing structure, the number of nursing directors and nurse managers had been reduced. Nurse managers were often assigned responsibility for two nursing units, with an expansion in the number of assistants or charge nurses reporting to them at the shift level Gelinas and Manthey, These additional duties likely leave the nurse manager with less time to provide clinical supervision or teaching Norrish and Rundall, Interview data from all three flagship hospitals in the study suggest the need for an ongoing, central locus of clinical leadership within the HCO Clifford, And in the — survey of 29 university teaching hospitals described above, researchers found that as the responsibilities of nurse executives were expanded, consolidation or downsizing of nursing departments occurred in 82 percent of hospitals.

Further, nurse manager positions were reduced in 91 percent of the hospitals, and nurse managers' span of control was broadened to include more than one patient care unit.

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Nearly half of the nurse managers were also given additional responsibility for supervising personnel other than nursing staff e. Assistant nurse manager positions were reduced in 68 percent of the hospitals. This effect also is reported in other studies of HCO reorganization of nursing services Ingersoll et al. The committee finds that strong nursing leadership is needed in all HCOs in order to 1 represent nursing staff and management to each other and foster their mutual trust, 2 facilitate the input of direct-care nursing staff into decision making on the design of work processes and work flow, and 3 provide clinical leadership in support of knowledge acquisition and uptake by nursing staff.


Recent changes in the responsibilities of senior nurse executives and nursing management in hospitals, in particular, may place these functions at risk. The committee therefore makes the following recommendation:.

Keeping Patients Safe: Transforming the Work Environment of Nurses.

Recommendation Although the committee did not find evidence supporting the use of one particular organizational structure for locating nursing leadership within any one type of HCO or across all HCOs, the intent of this recommendation is to institute among other management practices well-prepared clinical nursing leadership at the most senior level of management—e.

Many of the changes in nursing leadership described above were the result of organizational efforts to achieve greater efficiency Sovie and Jawad, This increased emphasis on production efficiency discussed also in Chapter 1 has been a hallmark of the hospital and health care reengineering initiatives of the last two decades Bazzoli et al. Concern that reorganization initiatives have focused on efficiency at the expense of patient quality also are commonly expressed by nursing staff involved in such initiatives Barry-Walker, ; Ingersoll et al.

Experts in patient safety have identified safeguards that can be used by HCOs to defend against an overemphasis on efficiency at the expense of reliability patient safety. First, HCO boards of directors should spend as much time overseeing an organization's patient safety performance as they do dealing with financial goals and performance Appleby, They should know 1 how patient safety is addressed in the HCO's mission statement; 2 what mechanisms are used by the HCO to assess the safety of its patient care environment; and 3 what the HCO's overall plan or approach is for ensuring patient safety and whether it has defined objectives, senior-level leadership, and adequate personnel and financial resources.

The board should also receive regular progress reports on patient safety Mohr et al. Further, a member of the HCO's senior leadership team excluding risk management should serve as chief quality and safety officer, comparable to the chief financial officer. Just as the latter individual is in charge of monitoring and strengthening the organization's financial performance, the chief safety officer should be responsible for patient safety measures and metrics Appleby, This responsibility can be met by developing indicators of patient safety and quality that are collected and monitored before and after change initiatives are undertaken Ingersoll et al.

Repeatedly, when asked how they would handle a situation, nurses told us that it depended on the situation, but that they felt free to ignore the formal structure if the situation demanded it. The perception of openness and trust was almost unbelievable; there was absolutely no reticence to share anything with us—good or bad.

Not a single nurse asked that any of our interview material be kept confidential. This open and trusting atmosphere is remarkable, especially because of its scarcity.