A Time to Lead

illustration of nurses in various roles throughout history

Nurses are trained to take charge. Now everyone knows why.

The COVID-19 pandemic has created challenges for nurses and altered the health care landscape in ways that were previously unimaginable. Throughout this crisis, nurses have found themselves in unprecedented positions, grappling with high-stakes decisions and adapting to new care situations and operational policies. Despite overwhelming conditions, they have continued their essential work of caring for the sick, advocating for those in need, and demonstrating respect and dignity for all persons for whom they provide care.

The pandemic has been devastating, but it has also been a moment for nurses. Extensive media coverage chronicles nurses’ heroic work on behalf of patients under adverse, pressure-filled conditions and at great personal risk as they work long hours and without proper equipment or protective gear. As stories abound of nurses stepping up to confront one of the worst public health crises in history, the public learned something that many take for granted — nurses are, by nature and education, leaders.

An Essential Core Competency for Every Nurse

Today’s health care systems are interdependent environments where nurses, physicians, support staff, and patients and their families each provide input. All must collaborate to find the best solutions and ensure the best patient outcomes. The onus to assume a leadership role is even greater outside of acute care environments, where nurses work autonomously with patients and families in community or home settings. A home health nurse working closely with a person who has Alzheimer’s may be more likely to notice and notify family members about an issue than a nurse working in a hospital.

Nurses, as the primary caregivers with the most direct patient contact, have enormous influence and an obligation to help guide the patient care team. In fact, nursing has been ranked the most trusted profession by Gallup polls for 19 consecutive years.

Studies reveal that when nurses lead, positive patient outcomes follow. For example, in the study “Clinical Leadership Development and Education for Nurses: Prospects and Opportunities,” which was published in the Journal of Nursing Management (2015), the authors conducted a thorough review of 20 previously published studies. Researchers linked 19 patient outcome variables to leadership by nurses including patient mortality, patient safety outcomes, adverse events, complications and patient health care use. The authors also found links between nursing leadership and lower patient mortality rates, as well as reduced medication errors, lowered use of restraints and fewer hospital-acquired infections. The study’s authors concluded that developing and supporting transformational nursing leadership is an important organizational strategy for improving patient outcomes.

Learn. Adapt. Grow. Repeat.

The commitment to a lifetime of learning and leading on behalf of patients begins with a nurse’s undergraduate education.

Given the demands nurses encounter in practice and the need for strong and effective leadership, the Duquesne University School of Nursing created a curriculum that provides opportunities for students to develop the knowledge and nursing skills they need while also growing in areas of professionalism, communication, collaboration and leadership.

“We talk with new students about three types of education they will receive — theoretical, professional and clinical,” says Dr. Kate DeLuca, associate dean for student affairs. “But there is more to the professional development element of their education than just interview techniques. It is about shaping them into the kind of nurse they want to be. Many students had an experience that inspired them to choose a career in nursing, such as a family member or a nurse who made an impact on their lives. We ask them to write down the qualities a good nurse has — like empathy or leadership — and then we discuss how to develop those qualities in them, too.”

The School of Nursing curriculum weaves leadership topics into coursework and clinical rotations to help students master these competencies. Active learning opportunities also enable them to apply their skills and gain real-world experience. One example is the clinical immersion experience connected to the Clinical Leadership in Professional Nursing course. Nursing students enrolled in the course complete a 21-week clinical experience at a University of Pittsburgh Medical Center facility, where they perform a variety of procedures for acute care patients and carry out other assignments under the supervision of a registered nurse. Students interact with patients and their families, and participate in unit-specific leadership, quality and safety activities. Students learn to recognize warning signs like deviations from acceptable patient health care status or standards, and then discuss the situation with unit staff and perform interventions. Along with building hard and soft nursing skills, participants network with professionals to gain a clearer understanding of the workplace, so they are better prepared following graduation.

A nursing education includes numerous opportunities for students to work with faculty and peers both inside and outside the classroom to develop leadership skills and insights. Along with memberships in the Duquesne chapter of the National Student Nurses’ Association and other campus professional and social organizations, student representatives sit on numerous administrative committees, ensuring them a voice in decisions that affect them. The experience also helps participants become comfortable with group dynamics and processes like collaborative decision-making that require them to advocate for a position.

A Focus on Nursing Ethics

Ethical leadership is also part of the competency equation.

“There are classes that deal specifically with ethical considerations in the profession, but ethics is woven into much of the coursework,” DeLuca says. “It is not just about big ethical questions. Common, everyday actions are also ethical considerations — like washing your hands to protect your patient.”

Dr. Michael Deem, assistant professor with a joint appointment in the School of Nursing and the Center for Global Health Ethics, defines ethical leadership as behaviors that follow accepted standards and demonstrate character and virtue, but also convey respect for others. For example, an effective nurse demonstrates cultural competence that allows movement beyond one’s frame of reference to view a situation from a patient’s perspective.

“Students must learn not only to follow rules and protocols, but also to act in their patients’ best interests, and to do it with respect for patients and families,” Deem says. “If a parent refuses to vaccinate their child, the response is not something students can practice on a mannequin. We need to teach them how to respond to vaccine hesitancy within the ideal of promoting the child’s health and to do it compassionately, without falling back on their own biases.

“It starts at the top, with deans and faculty modeling behaviors and a culture that encourages students to act in the same way,” Deem adds.

Leadership in the Age of COVID

The COVID-19 pandemic descended with little warning and forced educational institutions to the edges of creativity to enable continuity of instruction.

“Resiliency and the ability to adapt are key attributes for any leader,” says Dr. Torrie Snyder, clinical assistant professor and chair of the undergraduate nursing program. “This past year taught all of us a great deal about these characteristics and the importance of demonstrating them for our students and staff. Nurses must always be flexible, and I think that is much clearer now.”

To accommodate the shift to remote learning, Rosanna Henry, instructor and assistant dean for clinical skills and simulation education, had to create ways to replicate the hands-on environment of a state-of-the-art demonstration lab and then transfer it to students’ dorm rooms, apartments and homes. Henry worked with Joseph Seidel, assistant dean for instructional and clinical technology, to provide the software, hardware and connectivity students needed for online instruction. To supplement the curriculum, they developed demonstration videos for procedures like intubating a patient, and then engineered equipment to enable students to practice skills. For example, Henry found that connecting plastic tubing to a soda bottle approximated an airway passage well enough to enable students to practice proper suctioning techniques.

“Our faculty had just days to develop and master new teaching techniques and technology, and then prepare students to learn in a completely different way,” Snyder says. “Students did not miss important instruction by not being in the labs because they and their instructors worked together to ensure that the alternate approach succeeded.”

Leadership at All Levels

Snyder believes that nurses at all levels need strong leadership skills. “As nurse educators, it is important to embrace leadership in our institutional practices, values and beliefs,” she shares. “Students are influenced not only by what we say but how we behave as instructors, advisors and even as colleagues. It is important that we lead by example.

We have the potential to educate future generations of transformative nurse leaders who can serve as strong patient advocates and make decisions on how to improve the delivery of care and patient outcomes.”

“We are fortunate to have a strong administrative team that talks through ideas before we make decisions — hearing and debating the pros and cons,” DeLuca says. “We engage in that level of professional discourse and then, even if we disagree, we make a decision and move on. The final measure is what is best for the student.”

“The pandemic has been both a blessing and a curse,” Snyder notes. “We have been forced to step outside of the box and rethink the ways we do things — starting with how we educate our students —and ask whether we can and should change certain things. In the long term, I think some changes we have made will improve and promote positive outcomes in nursing education.”

Teaching during the pandemic also made certain basic concepts much more relatable.

“We always taught the importance of hygiene and protecting yourself in the workplace, but students by nature have that sense of invincibility,” Snyder says. “Now when we teach infection control and the importance of PPE, students are paying closer attention because the reasons are much clearer. We are also seeing greater acceptance of innovations like telehealth that make health care more accessible.”

Snyder points to another positive outcome of the pandemic — greater appreciation for the nursing profession.

The way the world views nurses is forever changed. “Until this happened, I think some saw nurses primarily as order-takers,” Snyder says.

“Media coverage of health care workers during the pandemic has been very positive, and has helped paint a much clearer and accurate picture of what we really do on behalf of our patients.” 

This article has been reprinted from Nursing Magazine, Vol. 6.

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