The Nurse Leader in the Community
alliances, p. 878
budget, p. 884
business plan, p. 884
coaching, p. 882
coalition, p. 878
collaborative, p. 873
complex adaptive systems, p. 876
conflict resolution, p. 883
consultation, p. 873
consultation contract, p. 877
contracting, p. 882
cost-effectiveness analysis, p. 885
delegation, p. 879
distribution effects, p. 875
empowerment, p. 879
external consultant, p. 876
internal consultant, p. 876
learning organizations, p. 875
managed care organizations, p. 872
microsystems, p. 876
negotiation, p. 877
partnerships, p. 872
political skills, p. 872
power dynamics, p. 883
process model consultation, p. 876
seamless system of care, p. 872
service delivery networks, p. 872
supervision, p. 882
systems thinking, p. 875
variance analysis, p. 884
vertical integration, p. 872
—See Glossary for definitions
Juliann G. Sebastian, PhD, RN, FAAN
Juliann G. Sebastian developed an interest in public health and community-based nursing while obtaining her BSN degree, when she provided care in rural Appalachia. Since then, she has cared for a range of vulnerable populations across the life span and in a variety of community settings, including adults who are homeless, low-income families, and frail elders in their home environments. Her doctoral preparation was in organization theory and health economics, and her research interests are in the area of community systems of care delivery for underserved populations. She was a member of the inaugural cohort of Robert Wood Johnson Nurse Executive Fellows (1998-2001), during which time she focused on development of models of academic clinical nursing practice. Her research and publications have focused on academic nurse-managed centers, community-based care, and primary care. She is a Fellow in the American Academy of Nursing and has held numerous leadership positions in professional nursing organizations. Dr. Sebastian serves as Dean of the College of Nursing at the University of Missouri–St. Louis.
Population-focused nurses have a responsibility to provide leadership in creating a new future for healthier communities. Members of the public ask whether better approaches to health care delivery might be developed that will ensure that all people around the world live in health-promoting communities and have access to quality health care as well as to health promotion and illness prevention services. Population-focused nurses practice in a variety of settings, including public health departments, community-based clinics, occupational health settings, schools, and managed care organizations. Leadership, management, and consulting skills are important to the success of client outcomes that depend heavily on cost-effective, efficient delivery of care. Care coordination and managing care transitions throughout the community, including acute and long-term care settings, is important to promoting a healthy community. Nurses need effective skills in communication, negotiation, and interprofessional practice and good leadership, management, and consultation skills, even if they do not have formal positions as managers or consultants.
Nurses must focus attention not only on the populations that are served by their organizations, but also on those that are not. Because they concern themselves with the total public, their focus is always on the future and on the interacting factors that influence the health of the public. Nurses work with partnerships of community members and community organizations. Partnerships can be complex and require time and thoughtful attention. This chapter examines the roles and functions of nurse leaders, managers, and consultants in the twenty-first century. It emphasizes nursing leadership in public health and community-based nursing practice, personnel management, and consultation with groups and individuals.
Major Trends and Issues
Ensuring client safety and quality of care, performing evidence-based practice, eliminating disparities in health care access and outcomes, and focusing on consumer participation in and satisfaction with care are key trends in health care.
The Institute of Medicine report titled To Err Is Human (Kohn, Corrigan, and Donaldson, 2000) focused attention on the incidence of health care errors. This is a concern in the community just as in hospitals and long-term care agencies. For example, studies in the United States (Metlay et al, 2005), Europe (Fialova et al, 2005), and Australia (Johnson et al, 2005) show that older adults living in the community are at high risk for medication errors. Sometimes this is because they are taking high-risk medications (Fialova et al, 2005), or because they cannot read instructions for medications (Georges, Bolton, and Bennett, 2004), or because they are not being taught how to take medications that have been prescribed for them (Metlay et al, 2005).
Evidence-based practice is another trend important for public health nurses. Basing clinical practice patterns and community programs on research and other forms of evidence such as best practice data is a key strategy for ensuring high-quality care. One example of evidence-based practice in a community setting is a smoking cessation relapse prevention program for new mothers (Groner et al, 2005) implemented by home health nurses. In this program, nurses used smoking cessation guidelines from the Agency for Health Care Policy and Research (now known as the Agency for Healthcare Research and Quality) to provide a cognitive-behavioral intervention for new mothers before hospital discharge, once in the home, and by telephone.
The health system in some local areas has been reorganized to provide a full continuum of services in a seamless system of care. Large, vertically integrated systems are able to do this. Vertical integration means that the system owns all of the services that clients might need (e.g., clinics, hospitals, and home health agencies). In other cases, free-standing agencies collaborate and contract with one another to achieve seamlessness. The goal is to reduce fragmentation, which should be helpful for vulnerable populations. Nurses coordinate clients’ care across agencies, but this new trend in the health care system places added emphasis on relationships, such as alliances, agency partnerships, joint programs, and participation in service delivery networks (Provan and Milward, 2006). Nurses actively participate in these groups and need good negotiating and political skills to be effective.
Another important trend is related to the movement toward more community partnerships (El Ansari and Weiss, 2006). The public has an increasing interest in becoming involved in planning for health services and in being active partners in their own care. Nurses need to be able to listen well and collaborate with lay community members, whose goals and ideas may differ from those of health care professionals. For example, people who were HIV positive who sought care in an infectious disease clinic were consulted about the implementation of an HIV prevention program within the clinic. The resulting input led to greater buy-in of key stakeholders and successful implementation of the prevention program.
The public is increasingly using the Internet, a wide variety of publications, and lay support groups to obtain health information. People need help deciding which information is good and how to best work with their health care providers to adapt information to their own health profiles. Those with low health literacy (see Chapter 31) need special help obtaining the health information necessary to be effective partners in health care (Committee on Communication for Behavior Change in the 21st Century, 2002; Ryan, 2009).
To know whether an agency is performing as expected, nurses must be familiar with their professional standards of care, the standards held by accrediting bodies, such as The Joint Commission, and guidelines for practice, such as those published by the federal Agency for Healthcare Research and Quality, the U.S. Clinical Preventive Services Task Force (2009), and the Task Force on Community Preventive Services (Zaza, Briss, and Harris, 2005). Nurse leaders also need to know how to use electronic health records and management information systems to link client outcomes with clinical and administrative processes. Registries are examples of clinical databases dedicated to certain population groups, such as people with cancer, diabetes, injuries, or population groups such as women. Nurses should know how to work with the taxonomies for nursing diagnoses, interventions, and outcomes of nursing actions (Bulechek, Butcher, and Dochterman, 2007) because these are being included in electronic health records and will help nurses identify changing health needs (von Krogh, Dale, and Naden, 2005).
One trend that combines the idea of partnerships with a structured method for rapid performance improvement is the use of collaboratives. A collaborative is a group of similar organizations that agree to use common processes for providing clinical care and share certain types of data so all may learn. A well-known example is the Health Care Disparities Collaboratives
method used by the Federal Bureau of Primary Health Care (Martin et al, 2007). Community health centers may apply to participate in collaboratives that target certain chronic health problems, such as diabetes or cardiovascular disease.
A major trend in public health is a stronger focus on implementing the core functions of public health and providing the essential services of public health (PHF, 2010). Competencies have been identified for generalist public/community health nurses that build on the core function and essential services (Education Committee of the Association of Community Health Nurse Educators, 2010).
Nursing leadership refers to the influence that nurses exert on improving client health, whether clients are individuals, families, groups, or entire communities. Nursing management, on the other hand, refers to the ways nurses organize and use resources when providing clinical services. These resources might be people, as when a nurse coordinates an interprofessional team, or financial resources. An example of managing financial resources is when a nurse monitors the budget for an immunization program to make sure that personnel time, supplies, and equipment are being used efficiently. Nurses also manage time. For example, home health nurses must manage their time in order to provide clients with direct and indirect nursing services, such as health education and making referrals, respectively. Leadership sets the direction, and management ensures that goals will be achieved. Nurses must possess strong clinical leadership and management skills to be effective, whether or not they hold management positions.
Consultation has been described as a process in which the helper provides a set of activities that help the client perceive, understand, and act on events occurring in the client’s environment. Clinical consultation increasingly focuses on ways to better coordinate the care delivery process across sites of care. Population-focused nurses have a breadth of knowledge that makes them desirable consultants for colleagues both inside and outside the organizations in which they work. For example, a nurse working in a home health agency might be called on by a school nurse to give suggestions about the most effective way to intervene for a child using a respirator. Another example that occurs frequently is the informal consultation provided by nurses in the community, who help nurses working in hospitals make effective community referrals. At the population level, nurses who consult with a local health department about developing a program for obesity prevention in school-age children are focusing their efforts on a particular target population. An example would be the nurse leader of a community-based diabetes program who works with clinical colleagues in a hospital to improve the self-management education for people with diabetes.
Consultation is closely linked with the ideas of empowerment and self-management. When consultants help clients identify and work through problems and learn new skills that clients see as most important, they are enabling clients to solve more of their own problems. This is very similar to the traditional nursing philosophy of helping people to solve their own problems, whether they are individuals, families, groups, or communities. Empowerment is consistent with Dorothea Orem’s nursing theory of self-care (Orem, 1991), in which she states that the nurse’s role is to promote clients’ self-care abilities.
Leadership and Management Applied to Population-Focused Nursing
One way nurses achieve leadership goals is by participating in a Healthy Communities (CDC, 2010) initiative at the local level. Working with others to develop policies for smoke-free public spaces is an example of promoting healthy living and working environments. Another example is collaborating with consumers and professionals from other disciplines to evaluate root causes of medication errors in home-bound elders and design a process improvement strategy to reduce errors.
An example of how nurses achieve management goals occurs when they develop plans for broad-based immunization clinics, such as smallpox vaccination clinics. Doing this in advance of confirmed bioterrorism is a way of preparing to meet an emerging community health need that achieves goals of protecting the public’s health and helping personnel work effectively and efficiently. Table 40-1 shows examples of ways population-focused nurse leaders and managers facilitate primary, secondary, and tertiary preventive services.
|LEVELS OF PREVENTION||NURSING LEADERSHIP (SETS GOALS)||NURSING MANAGEMENT (DIRECTS USE OF RESOURCES)|
|Primary (prevention of illnesses or problems before they begin)||Works with a community coalition to design a broad-based strategy for ensuring health and social needs of uninsured and underinsured populations are met.|
Works with nurses and interprofessional colleagues to develop goals related to preventing health care errors and ensuring client safety.
|Develops policies and procedures for a referral program for low-income mothers and children to obtain nutrition services.|
Ensures that individuals and families understand care routines to promote adherence and reduce chances of health care error.
|Secondary (screening for illness and treatment of health problems before they worsen)||Works with local government and health department to design lead screening and abatement programs in high-risk census tracks.|
Monitors data about a caseload of clients to determine if patterns are developing that might indicate a health problem or issue needs to be resolved.
|Designs protocols for lead screening program and hires staff to implement program.|
Works with other members of care team to design protocols to improve specific health outcomes.
|Tertiary (treatment of health problems to foster stabilization or delay exacerbation)||Participates on a planning commission with local health department, hospitals, police, and political leaders to update a community-wide disaster response plan that accounts for bioterrorism.|
Collaborates with interprofessional teams to set goals for performance improvement and rapid changes in quality of care problems.
|Serves as chair of a committee that organizes, staffs, and monitors budget for a smallpox vaccination program.|
Monitors implementation of performance improvement activities to ensure timely and appropriate completion or revision as necessary.
Theories of Leadership and Management
Leadership and management theories help explain individual and group behavior as well as organizational and system dynamics. Theories that help explain and predict individual behavior often focus on employee motivation and job satisfaction. Some theories address interpersonal issues such as leadership, communication, conflict resolution, and group dynamics. Working with consumers, staff members, and other health professionals in an adult day-care facility to design a memory improvement program for participants exemplifies the use of these theories. This type of project requires knowledge of motivation and leadership, team work, change theory, and project planning, management, and evaluation.
Organizational and systems theories explain issues at a broader agency or community level. These theories focus on the best ways to organize work, on how to obtain the resources necessary to accomplish agency goals, on organizational level change, on power dynamics, and understanding systems. Systems theories help explain the dynamics of rapid, interconnected change and the emergence of patterns of activity (Holden, 2005).
Good leadership skills are essential for nurse leaders and are among the key competencies for generalist public/community health nurses recommended by the Quad Council of Public Health Nursing Organizations (2009) and for “entry level public health professionals” by the Council on Linkages Between Academia and Public Health Nursing Practice (2010, p 1).
The transformational leader is able to transform, or change, the situation to one that differs from the status quo (Bass and Bass, 2008). Transformational leaders are sometimes found in learning organizations, or agencies that create cultures that support ongoing learning, experimentation, and creation of new knowledge (Roussel, Swansburg, and Swansburg, 2006). Transformational leadership is essential to promoting a culture of safety and positive work environments for others (Committee on the Work Environment for Nurses and Patient Safety, 2004).
Systems theories and systems thinking emphasize the interdependence of multiple parties. Nurses often recognize interdependence of units within an agency but may be less aware of agency interdependence. Economists analyze how distribution of resources affects policies, which players in a system will be influenced by policies, and how they will be influenced. These are called distribution effects. For example, if the federal government reduces money for health and social services, the clients of those services may be negatively affected. Employees of service agencies are also affected because agencies are likely to downsize to manage the reduced funding. Consequently, employees may either lose their jobs or experience wage cuts. Others likely to be affected include voluntary agencies and religious groups who might be expected to provide more services.
Roy’s adaptation model of nursing has been extended to include nursing management (Roy, 2002). Roy argues that agencies are composed of interdependent systems. The role of nurse managers is to help the agency adapt to changing circumstances in the most effective way possible. Roy’s model is particularly helpful for explaining and predicting how nurse managers and consultants can help agencies adapt to change. Nurse leaders should analyze how well interdependent units function to achieve agency goals. Furthermore, nurse leaders function as change agents because they foster agency adaptation. Complex adaptive systems theory accounts for the unpredictability of the behavior of people and organizations (Holden, 2005). The combination of unpredictability and interdependence leads to disequilibrium and potentially to adaptation and growth. Communities exemplify complex adaptive systems. Understanding the importance of relationships and tension in the midst of change led one group to design a primary care team-based approach to reflection as a way to improve care (Stroebel et al, 2005). Nurse leaders must understand the analytical, political, and communication skills needed to work effectively in these systems.
Clinical microsystems are the systems, people, information, and behaviors that take place at the point of client care (Nelson et al, 2008). Evidence-based clinical improvements can be implemented quickly in a clinical microsystem that has sufficient data about the practice, information systems that support clinical decision making, and a well-functioning team. For example, nurses working in a mobile health unit are part of a clinical microsystem. The team can make rapid changes in responses to quality problems if team members work well together and the mobile health clinic has an information system that makes it possible to track population health outcomes and clinical practice patterns.
Nurse Leader and Manager Roles
First-line nurse managers may be team leaders or program directors (e.g., director of a satellite occupational health clinic or director of a small migrant health clinic), whereas mid- or executive-level nurse managers may be division directors (including multiple programs or departments), local or state commissioners of health, or directors of large home health agencies with multiple offices. They function as coaches, facilitators, role models, evaluators, advocates, visionaries, community health program planners, teachers, and supervisors. Population-focused nurse leaders have ongoing responsibilities for the health of clients, groups, and communities, as well as for personnel and fiscal resources under their supervision. Nurse leaders may have positions as managers or they may be excellent clinicians and change agents who are seen as opinion leaders.
The goal of consultation is to help others empower themselves to take more responsibility, feel more secure, deal with their feelings and with others in interactions, and use flexible and creative problem-solving skills (Sabatino, 2009). The functions of a consultant differ from those of a manager because consultation is typically a temporary and voluntary relationship between a professional helper and a client. The similarities between consultants and leaders are in their emphases on empowerment and helping others develop. Consulting relationships are based on cooperation and respect between consultants and clients, who share equally in problem solving (Argyris, 1997).
The nurse’s job responsibilities may include internal and external consultation. Internal consultants are members of the organization who work in a temporary capacity to help the client create or sustain change (Lacey and Tompkins, 2007). For example, a nurse may be employed to consult with other nurses in the agency about client care problems or, as an employee of the health department, may serve as a consultant to a local community retirement center about the public health care needs of its residents. If the nurse is an internal consultant, the nurse is employed on a full-time salaried basis by a community agency in which the consultation takes place. If the nurse is an external consultant, the nurse is employed temporarily on a contractual basis by the client. The client of the external nurse consultant may be a colleague, another health provider, or a community group or agency. Consulting may occur informally when a staff nurse asks a colleague for advice or help in solving a problem. The nature of the consultation relationship, whether it is internal or external, should not change the goal of consultation.
Theories of Consultation
Several models of consultation have been developed. Although nurses often consult with individuals about their own health care, or with another nurse or health professional about the needs of an individual client, this section emphasizes population-based consultation. At this level, the nurse focuses on the needs of a group, organization, or community. The client in this case is an organization or group. Content models emphasize the role of consultant as the expert who provides specific answers to problems or issues identified by the client. This approach has the advantage of being relatively quick and often responsive to client requests, but it does not help engage the client in problem solving and learning how to address similar issues in the future (Schein, 2009). This chapter focuses on Edgar Schein’s model of process consultation because it is consistent with the nursing process and with nursing values of empowering clients and collaboratively working as partners with clients. The process model consultation focuses on the process of problem solving and collaboration between consultant and the client. The major goal of the process model is to help the client assess both the problem and the kind of help needed to solve it (Schein, 2009). Process consultation includes assessing the underlying agency culture that influences the problem and its solution (Schein, 2010). Both consultant and client participate in the problem-solving steps that lead to changes or to actions for problem solution.
Although consultants should emphasize process consultation, they should be willing to share their expert knowledge when appropriate. Because process consultation is collaborative, Schein (2009) recommends that consultants be willing to offer opinions and advice at all stages of the consultation process. Thus, although the major emphasis should be on process consultation, consultants may find it effective to integrate both context and process.
In the process model, the consultant is a resource person whose primary goal is to provide the client with choices for decision making. Process consultation includes the same steps as the nursing process: establishing a nurse–client relationship based on trust to assess the problem, planning and implementing actions, and evaluating the outcomes of nursing interventions. Nursing interventions may be described as direct client care or as consultation activities, depending on the goal of the intervention.
Consultation may occur before a problem occurs or after a problem exists. For example, a parent–teacher council developing a school-based family center contacts the nurse to assist with options for future nursing and health care for the students and their families. The board wishes to be proactive and plan for the needs of high-risk students and families. The administrator of a minimum-security prison has found that inmates are missing work for minor health problems and that health costs are skyrocketing. The nurse is asked to help explore solutions to the problem. Prison administration is reacting to an existing problem requiring immediate intervention.
The client is identified by determining who in the situation has the problem and needs to change. The following vignette illustrates this point:
Barry Henderson, RN, has been asked by the pastor of his congregation to consult with the parish council regarding the potential establishment of a health ministry. Barry decides that the consultation contract needs to include representatives of the parish council and parishioners themselves to find effective answers to the question. He realizes that time would be wasted and resistance to change would still be present if the focus were on only one group at a time. If he met separately with the parish council, they may decide such a program should include only one set of services. The parishioners either may want a different set of services or may desire to have services and programming organized in a very different manner. For example, the parish council may be especially interested in blood pressure screening, whereas the parishioners may be interested in wellness classes to keep the congregation healthy and in home visiting for those who are ill. After spending much energy meeting with both groups separately, Barry believes that by being a messenger between the two groups rather than a facilitator for problem solving, the consultant role has been diluted. On the other hand, by meeting with both groups together, Barry could serve as a resource, helping them explore all viewpoints and alternatives for developing the new program. In this case, both the parish council and the parishioners are Barry’s clients.
The consultation relationship is based on expectations. The consultant has expectations concerning time, money, resources, and the participation of the client in the process. Clients have expectations about what they will gain from the consultation relationship. Discussing the terms of a consultation contract makes expectations explicit, lessens the likelihood of violations of contract terms, and reduces the risk of additional demands being made on either party. Areas to include in the written consultation contract are as follows: