The rate of change is not going to slow down anytime soon. If anything, competition in most industries will probably speed up even more in the next few decades.
—John P. Kotter (1995)
An Evolving National and Provincial Landscape
Health care environments have evolved over the years to become highly complex with less predictability; they are constantly undergoing change and restructuring. This has been a result of many factors. The most crucial are changes in the health of populations served and their subsequent health needs paired with available resources and capacity of the health system to meet these needs. Additional factors impacting health care over the past two decades include: increases in the use of technology, a rapidly changing multigenerational workforce, changing requirements of management accountabilities, a greater emphasis on performance measurement, the challenge of managing with scarce resources, rapid growth in inter- and intra-professional teams with changes in scope of practice, and higher consumer expectations. These many factors have influenced and impacted the roles of nurse managers and leaders in ways that have not traditionally been experienced in organizations.
In July of 2011, the Canadian Nurses Association and the Canadian Medical Association published “Principles to Guide Health Care Transformation in Canada.” In response to health care system transformation and restructuring across Canada, this document was developed to provide a common framework to guide regional and jurisdictional change. It identifies the importance of following the five principles of the Canada Health Act and incorporates the Triple Aim Framework from the Institute for Healthcare Improvement (IHI). The principles in this document are focused around three main themes: (1) enhance the health care experience, (2) improve population health, and (3) improve value for money. These three themes are now a critical focus in nurse managers’ work environments today (CNA & CMA, 2011).
A second document published by the Canadian Nurses Association titled “Registered Nurses: Stepping Up to Transform Health Care” (CNA, 2012) outlines many examples of how registered nurses are putting key principles into action based on the three main themes. Illustrations are provided of the innovative ways in which nurses are improving our health system across Canada today. On a national level, both publications serve as guiding framework documents for nurse managers and leaders in today’s health care environment pointing to new ways of working together across care boundaries to better meet the health needs of the populations we serve.
On a provincial level, Saskatchewan is now beginning a large-scale transformation of its health care system. In December of 2016, a report on system restructuring titled “Optimizing and Integrating Patient-Centered Care” was released by an appointed Advisory Panel of the Saskatchewan government. This panel released 14 recommendations, with a key recommendation focused on consolidating existing health authorities into one provincial authority to “achieve administrative efficiencies and improvements to patient care” (Saskatchewan Advisory Panel, 2016, p. 3).
Two earlier Saskatchewan reports that continue to influence the nursing management landscape in the province today include the “Primary Health Care Framework Report” (Saskatchewan Health, 2012) and the “Patient First Review” (Saskatchewan Health, 2009), both of which identify transformational opportunities for our health care system and nursing management.
Significance for Management and Leadership
These previously mentioned reports emphasize the need for nurse managers and leaders to employ the necessary skills to manage increased complexity in this changing landscape. Managers are required to think beyond the traditional silos and extend their view to focus on the patient journey along a care continuum. As our evolving Canadian health care system places more emphasis on health promotion, primary care, and community-based care, nurse leaders are also being challenged to move from organizations that have had a more controlling and directive style of management to one where engagement, empowerment, and recognition of the unique strengths of all individuals are essential. Because of system transformations, two key areas of change for nurse leaders in our health care system relate to workforce impacts and management system changes.
Despite challenges associated with a changing workforce and increased accountability for scare resources, nurse leaders and managers provide a crucial function in creating healthy work environments. There is growing evidence in the nursing literature about the positive impact of a healthy work environment on staff satisfaction, retention, patient outcomes, and organizational performance (Sherman & Pross, 2010).
A key factor in the changing workforce is the multigenerational makeup of health care organizations today. Our current workforces consist of mixed generations at all levels. Sherman (2006) identifies four generations with distinct attitudes, beliefs, work habits, and expectations, noting that this age diversity will continue for years to come. Spinks and Moore (2007) reported on Canadian generational diversity along with cultural diversity seen at all levels of organizations.
Another major challenge facing nurse leaders today is creating healthy work environments, keeping staff engaged and effectively retained. Mate and Rakover (2016) examined the concept of sustaining improvement in health care, taking into account changes in the Saskatoon Health Region (now part of the Provincial Health Authority) during this time of transformation, emphasizing the critical role of leadership both at the unit level and on the front line. They emphasize that nurse leaders are local champions who must work directly with staff engagement through coaching, team building, daily communicating, and demonstrating the ability to consistently function and manage the new standard processes in order to sustain achievements.
Another workforce impact is the rapidly changing nature of intra- and interprofessional teams. As health systems transform and more attention is paid to the care continuum and the patient and family journey, there is a heightened focus on effective functioning of all teams in touch with the patient and family. Scope of practice changes required to keep up to the changing population needs have led to changes in health care providers’ role on the many teams with whom the patient intersects across the care continuum. The changing nature of teams now requires managers to be attuned to role and scope changes to ensure care is effectively coordinated and integrated during the patient journey.
As early as 1973, in his review of health care in Canada, Robertson recommended the education and deployment of nurse practitioners (NPs) across the health care system, as a way to improve continuity of care and promote efficiency in the system (Stahlke, Rawson, & Pituskin, 2017, p. 488). NPs are “registered nurses who have additional education and nursing experience, which enables them to:
- autonomously diagnose and treat illnesses;
- order and interpret tests;
- prescribe medications; and
- perform procedures.” (Canadian Nurses Association, 2016)
Dorothy Pringle (2007) stated that NPs meet the “needs of patients that are not being adequately met by the healthcare system with its current configuration of roles” (p. 5). Their additional education and advanced skill set support them in providing leadership in health care. The role and performance of NPs has been found to be comparable to physicians across many aspects of care (Stahlke et al., 2017). Their study, referenced in the Research Note below, examines patient perspectives on NP care and further identifies the value of the NP within the health care system.
Stahlke, S., Rawson, K., & Pituskin, E. (2017). Patient perspectives on nurse practitioner care in oncology in Canada. Journal of Nursing Scholarship, 49(5), 487–495. doi:10.1111/jnu.12313
“The purpose of this study was to add to what is known about patient satisfaction with nurse practitioner (NP) care, from the perspective of breast cancer patients who were followed by an NP” (Stahlke et al., 2017, p. 487).
Nine patients in an outpatient breast cancer clinic were interviewed about their experiences with NP-led care. These experiences were highly consistent among the patients. Patients were initially surprised that they would receive their ongoing care from a NP. However, as care progressed, several of them were relieved to be assigned to the NP, because those assigned to the doctor were the “sicker” people. They were seen by the NP for almost their entire course of treatment. Patients were comfortable and confident in the NP care; however, they continued to believe that the physician was in charge. The NPs were “described as being more ‘hands-on’ and it was said that ‘they look at the bigger picture . . . dealing more with the individual’ and tapping into the patient’s own strength and resources for healing” (Stahlke et al., 2017, p. 491).
“Despite any initial misgivings or misunderstandings, these patients unanimously felt strongly positive about their NP-led care experiences, explaining that the NP was ‘a bonus’ (P6). That ‘the experience was wonderful’ (P5) and ‘she was just terrific with me’ (P5). One summed up the general sentiment, saying, ‘I’ve just been so fortunate. It was a gift. She’s a gift’ (P9)” (Stahlke et al., p. 491).
Application to practice
Despite the role ambiguity between the physician and NP, the patients valued the leadership of the NP in their care. Patient satisfaction is documented as being closely linked with better patient outcomes (Thrasher & Purc-Stephenson, 2008) and consequently the value of the NP role has become more evident. “NPs hold the potential to transform the patient experience and offer access to excellent, patient-centred care” (Stahlke et al., p. 492).
Figure 16.1.1 Celebration of the Birth of the Saskatchewan Association of Nurse Practitioners
Focusing on Quality Improvement: Management systems changes
Saskatchewan has been engaged in a transformational approach to management systems through a method of provincial strategy-setting “to set priorities, determine goals for the system, establish plans to achieve the agreed-upon goals locally and provincially, and measure progress toward these goals” (Health Quality Council, 2010).These changes have lead to an increased inclusion of nurses in decision making at various levels. As of 2013, all management staff in Saskatchewan received training on the Lean management system, a quality assurance approach. The training contained a consistent management approach for all leaders and managers in the province with standard processes that cascade up and down the management hierarchy. This approach and increased transparency of organizational direction required managers and leaders to develop and sharpen their communication skills, along with their skills for engaging staff and leading change initiatives. A greater emphasis on performance measurement also required managers and leaders to develop new skills for data collection to monitor various aspects of their unit’s performance, to learn how to display data on charts and graphs, and to use this information to tell a story about how the care aligns with and contributes to the overall provincial strategic directions. Inherent in this approach are concrete activities such as visibility walls, daily huddles at all levels of the organizations, and quarterly and annual reviews. As leaders of these activities, nurse managers and local unit leaders are required to engage staff on a daily basis as they communicate overall direction to their staff and work to build engagement in outcomes. These new processes are highly inclusive of all members of the health care team including patients and families.
Overall Impact on Leadership Styles
Chapter 1 of this textbook described various leadership styles. Strengths-based nursing leadership “redirects the focus from deficits, problems and weaknesses to use strengths that include assets and resources to manage problems and overcome and contain weaknesses” (Gottlieb, Gottlieb, & Shamian, 2012, p. 1). This style is also seen to support an environment of intra-professional teams and is a perspective that places the person and family at the centre of care.
Essential Learning Activity 16.1.1
For additional local information on the role and scope of nursing practice, consult the Saskatchewan Registered Nurses’ Association webpage on Nursing Practice Resources.
From the Field
Be able to clearly articulate what the transformed organization will look like to staff by providing concrete information on what you know as a manager, and what you don’t know, and regularly getting up-to-date, reliable information during the change.
Increase communication frequency and methods with staff during transformative change, using a variety of methods and communicating the same message a minimum of seven times.