Enhance strategic planning and execution skills through leadership investment

FigureNURSE LEADERS ARE critical to creating healthy work environments where staff thrive and patients receive excellent care.1,2 One reason why the American Nurses Credentialing Center's Magnet® program requires organizations seeking recognition to provide evidence of a robust nursing strategic plan is because organizations with healthy work environments that readily adapt to change have leaders with demonstrated competencies in strategic planning skills.3 The knowledge and skills related to strategic planning require that leaders ensure the development, alignment, and execution of such plans in complex systems. This exemplar presents one CNO's decision to invest in leadership development for the nurse executive team with a curriculum based on the American Organization for Nursing Leadership (AONL) nurse leadership competencies integrated with the strategic planning process. The investment resulted in positive outcomes for leaders and the organization. BACKGROUND This exemplar occurred in early 2023 in a four-time designated Magnet health system after the COVID-19 surges. The system consists of inpatient and outpatient services. The 500-bed acute care hospital provides inpatient care with a Level II trauma center, more than 120,000 annual ED visits, and a Level III neonatal ICU with over 2,500 deliveries annually. Outpatient services include primary care, medical specialties, ambulatory surgery, wound care, and home care. A new CNO's transition to the organization required learning the culture, systems, and challenges. Nurse staffing concerns existed, and the internal turnover among RNs was in line with the national turnover rate of approximately 21%.4,5 Several nurse leader positions were vacant or filled with interim leaders or with individuals new to their positions. The CNO prioritized completing an assessment of the nurse executive team's capabilities to determine strengths and development needs through an evaluation of their current work and interviews with members of the team. The ability to align and execute priorities was a concern. Investing in leader development was identified as a key priority to create a shared leadership language, generate strategic goals, and elevate expectations for leadership competencies. Providing meaningful leadership development to the nurse executive team wasn't possible with existing internal resources. The CNO sought external faculty with nursing leadership expertise and dedicated time for curriculum design, facilitation, and individualized coaching. The contracted external faculty was previously hired for leadership development and had endorsements from the leaders who participated in those development opportunities. THEORETICAL FRAMEWORKS The Donabedian theoretical framework model of structure, process, and outcomes was used in the leadership development program design and implementation.6 The utility of this framework is twofold. First, the Magnet recognition program uses the Donabedian model. Second, nurse leaders can find examples of its use extensively throughout healthcare literature. Adult learning theory served as the theoretical underpinning for curriculum design and delivery, primarily Mezirow's transformative learning theory and Kolb's experiential learning theory.7,8 Critical reflection to challenge the learners' perspectives and skill application to current practice guided the structure of interactive exercises within a group of trusted peers and postwork for deeper learning.7,8 The AONL Nurse Leader Core Competency model served as the conceptual framework for curriculum design.9 The AONL competencies give nurse executives an avenue for shared perspectives rooted in the work occurring in practice.9 The model outlines leadership practices in the domains of professionalism, business skills, relationship management, and knowledge of the environment, based on the foundational principle of the leader within. The leader within anchors all domains around the individual's capacity for self-understanding. The AONL model and leadership development experts support the emphasis on strengths-based development and a whole-person approach, which implore leaders to rely on what they already possess for maximum benefit in their personal journey of development and growth.10,11 STRUCTURE AND PROCESS Participants included all eight members of the nurse executive team, who held the titles of executive director, associate chief nurse, or vice president. The program consisted of three distinct offerings: nurse executive retreat, leadership development series, and individualized coaching. The nurse executive retreat and each development session had defined learning objectives related to each of the content areas included in Table 1. TABLE 1: - Leadership curriculum map Strategic planning and leadership development series Nurse Executive Retreat Development Session 1 Development Session 2 Development Session 3 Development Session 4 Strategic Planning Looking Inward Assessing Structure and Process Leading to Outcomes Meaning in Leadership Executive team and CNO Executive team Executive team Executive team Executive team Create alignment on the strategic goals and role clarity for executive team via these key topics: Setting the executive team vision Determining strategic goals and desired outcomes Identifying critical success factors Develop leadership practices that promote balance and sustainability via these leadership skills: Self-awareness and reflection practices Diagnosing situations with clarity and honesty Truth-telling in communication Enhance executive team effectiveness as influential leaders by revisiting the strategic goals with these factors in mind: Healthy work environments Vision and priority setting Influencing skills Accelerate progress in implementing the strategic plan by developing skills in: Leading complex change Telling the story with data Supporting change efforts Support leaders in elevating personal development and professional expectations around: Preventing burnout Leaders' role in advancing health equity Practicing resiliency and connecting to joy in leadership © 2024, Canopy Consultants Inc., www.canopyconsultants.org. Reprinted with permission. Nurse executive retreat. The nurse executive team and the CNO attended the retreat. To start the day, the CNO shared reflections on his vision for nursing. The executive team identified strategic priorities for the nursing division in alignment with the health system's strategic framework through facilitated dialogue. The team noted the congruence of nursing priorities within the health system strategic plan and their alignment with patient needs. This customized session included content on best practices for strategic planning and team discovery of their collective strengths via participation in the Gallup CliftonStrengths Assessment.12 Guided by their shared vision and the organization's priorities, at the conclusion of the retreat, the executive team agreed on three strategic goals: provide high-quality care to patients and colleagues in a safe environment; create an environment that attracts and retains the most exceptional people; and build trusted relationships with colleagues to strengthen our vision and achieve shared outcomes through teamwork. During the leadership development series, the nurse executive team further refined the goals and associated interventions and measures, and they began to work on executing the strategic plan. Leadership development series (four sessions). The nurse executive team, without the CNO, attended the development series. This cohort-based leader development series engaged leaders in participatory learning to enhance their leadership skills and support habits of influential leadership practices. The American Nurses Association approved 7.5 continuing nursing education hours per session. Each session occurred in person and was scheduled 2 to 3 weeks apart with no more than 30 to 60 minutes of pre/postwork assigned per session. Time between sessions focused on the individualized application plans developed by the learners at the end of each session, at which time they identified how they planned to integrate new insights, change perspective, or adjust their approach in a specified leadership challenge. Immediate skill application provides tangible examples of theory in practice and serves as a reaffirming practice for the nurse leaders to engrain their learning. Subsequent sessions started with a review of the individualized application plans to ensure ownership for personal growth, reflection on skill practice, and group learning through peer integration of new skills into practice. Adaptations to the series met the specific needs of this executive leadership team, which were to coalesce as a team, deepen their leadership practices, and further refine the nursing strategic plan. The series supported participants in developing leadership competencies, creating agency, enhancing the work environment, finalizing strategic goals, and generating outcomes at the team and organizational levels. The series ended with a working draft of the strategic plan based on the insights, discoveries, and decisions made during the leadership series. Individualized coaching. Coaching services were available to the nurse executive team to extend learning and engrain new practices. The executive, with input from the CNO, set the objectives for coaching outcomes. Coaching was provided during 16 sessions, each of which was 50 minutes long, with a certified coach via a virtual meeting platform. All coaching included supporting the executive with the elements of the strategic plan the executive had responsibility for and any additional objectives the executive identified. Of the eight nurse executive members, five decided to participate in coaching. DATA COLLECTION AND ANALYSIS An institutional review board approval wasn't needed given the quality improvement nature of this work. Qualitative and quantitative measures were collected to evaluate the impact of this investment in leadership development. Participants completed a preassessment utilizing the AONL Nurse Leader Competency Assessment Tool: Self-Assessment, based on their current roles as nurse executives.9 A postassessment was completed with the same tool within 2 weeks after the program ended to allow a paired t-test analysis of the results. Additionally, all participants provided postsession evaluations assessing the extent to which the learning objectives were met. Participants provided qualitative comments on their didactic experience and application of the curriculum to their leadership practice. Finally, nursing turnover rates and key clinical quality outcome metrics, such as patient falls per 1,000 patient days and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)—Nurse Communication ratings, were collected as a baseline practice for the organization and were examined before and after the leadership programming and learning application took place. RESULTS Participant results Participants reported that they strongly agreed (89.1%) or agreed (9.7%) that all objectives in the sessions were met. The following comments from participants, when asked about the program's strengths, represent themes from the group and demonstrate the value they found in the sessions: “Applying principles to real-life work situations” and “How each session reflects and builds on the subsequent session.” Although explicitly asked about weaknesses of the program, there were no comments provided. The CNO noticed a marked increase in the nurse executive team's preparation for meetings, facile use of the language and utilization of tools provided for leading change, and project management. Examples included reporting out data for agreed-upon measures, dialogue about strategies to empower the nurse managers, and recognition of the change management process in leading their teams. Additionally, unsolicited comments from nurse managers about the nurse executive team's professionalism and expertise in disseminating the strategic plan provided more evidence of the integration of skill development and supported the positive impact of the program. Comparison of the pre/post. The executive team's results for the AONL Nurse Leader Competency Assessment Tool: Self-Assessment revealed an increase in self-reported scores on three of the four subscales (such as knowledge of the healthcare environment, leadership, professionalism, and business skills) (see Table 2).9 The improvement in business skills was statistically significant (P = .04). The baseline skills of the nurse executive team were high, so the change in competency scores, although improved, didn't rise to the level of statistical significance with such a small cohort. The significant increase in the business skill scores is attributed to the curriculum framing around the strategic planning and execution processes. TABLE 2: - Competency pre/post data analysis Nurse executive AONL competency self-assessment (n = 8) Subscale Communication Knowledge Leadership Professionalism Business skills Mean T1 3.96 3.71 3.96 4.34 3.39 Mean T2 3.89 3.89 4.06 4.36 3.74 P two-tailed .47 .24 .58 .82 .04∗ ∗Statistically significant Organizational results Clinical quality measures related to the strategic goals served as the basis for evaluating how the leaders applied their learning to achieve positive patient outcomes across the health system. One example of how executing the strategic plan resulted in improved quality outcomes was implementing the bedside shift report on all inpatient units as an intervention to reduce patient falls and enhance nurse communication with patients. The nurse executive leading this goal applied learning about forming and empowering a work group, setting a clear aim statement for the work, defining measures, and leading through the change process. The implementation of a bedside shift report led to decreased patient falls and an increase in patient satisfaction as measured by the HCAHPS survey responses regarding nurse communication (see Table 3). The fall rate improved from 3.0 falls per 1,000 patient days in the two quarters before the intervention to 1.9 in the next two quarters. These results weren't seasonal changes, as the previous year in the same two quarters showed fall rates of 2.9 and 2.3. When comparing the four quarters before and after the beside shift report intervention, the fall rate changed from 2.7 to 2.2, a 19% decrease in the patient fall rate per 1,000 bed days. The HCAHPS Nurse Communication score also improved from the 62nd to 68th percentile when comparing the four quarters before and the four quarters after the bedside shift report implementation. These two measures provide evidence of the nurse executive's facilitation of leading this practice change via the skills learned during the development sessions and the sustainability of the learning. TABLE 3: - Organizational quality results pre/postintervention Fall rate per 1,000 patient days Pre Post 4 quarters preceding 4 quarters succeeding 2.7 2.2 HCAHPS nurse communication Pre Post 4 quarters preceding 4 quarters succeeding 62nd percentile 68th percentile Return on investment The total cost for all three aspects of the programming (team retreat, leader series, and individual coaching) was $41,000, representing less than half the average RN annual salary of $94,480.13 The focus of the development was execution of the strategic plan, and one of the plan goals was to improve direct care nurse retention. The return on this investment is the equivalent of the organization retaining one RN for 6 months longer than it would have otherwise. The nursing turnover rate improved from 25% preintervention to 16% postintervention and has sustained improvements to 12% year-to-date. This reduction in direct care nurse turnover more than covers the cost of the investment. LIMITATIONS This exemplar has a few limitations. It depicts one organization's journey to address its nurse leaders' development needs and may not be applicable or transferable to other organizations. The sample size is small, and the results are from a short time frame with a group of leaders with high baseline leadership skills. The competency pre/postdata are self-reported by the participants and only reflect their perceptions of growth. The CNO's assessment of his team was observational and didn't utilize a validated tool; therefore, it's open to bias and doesn't have interrater reliability. DISCUSSION AND IMPLICATIONS Given the current realities of healthcare budget constraints, it can be challenging to advocate for funding leadership development programs. However, when considering the influence of leaders on direct care nurse turnover and patient quality outcomes, the business case for this investment becomes clearer. Organizational leadership is one of the most influential components of healthy work environments in which patients receive excellent care and staff thrive.1,2 Investment in leader development has an impact beyond individual gain and should be a focused priority for any nurse executive. Providing leadership development to the executive leadership team during the transition between CNOs afforded the team a safe learning environment in which their perspectives could be understood and challenged. Anchoring the development around the nursing strategic plan afforded tangible application to practice and translated into demonstrated organizational outcomes. The benefit of utilizing external faculty with abundant clinical operations expertise is reflected in the qualitative comments of the leaders who applied their learning to real-life situations. Additional evaluation of this leadership programing should be conducted in different organizations across longer time frames to see if participant and organizational results and the return on investment can be replicated. The focus of this exemplar was the impact of the development program at the executive level. The next iteration of evaluation should extend to include all members of the nurse leadership team who had development opportunities made available to them. In addition to the executive team, this included: direct care nurses in leadership roles (attending/charge/resource nurses), and formal frontline leaders, such as nurse managers, program coordinators, and professional development specialists. Participants were selected based on role, time in current role or in other formal leadership positions, and their manager's support. Evaluating all leadership levels would provide a more comprehensive assessment of outcomes that rely on the contributions of leaders across all layers. TRANSFORMATION DURING TRANSITION This exemplar demonstrates that investment in strengths-based development and skill application during a period of leadership transition can have a positive impact on executive leaders and their ability to align on and execute strategic priorities. Healthcare organizations that use evidence-based leadership competencies and permit deep learning experiences with expertly facilitated cohort classes can transform their professional care environment and improve clinical operations, even during times of leader transition.