Top Ten Lessons For CNOs!

10) Build around a common vision, connecting to the BIG picture.
Choose easy, high impact themes, such as: Exceptional Care, Value Creation, Culture of Excellence, and Transformative Growth. These four areas of focus set the aspirations of the health system. As a Nursing Executive Team, facilitate annual retreats to align nursing’s goals around these strategic themes. Discuss ideas for standardization/centralization to reduce costs. It is important to assign ownership to you, other leaders, and staff. Parsing out leadership for some strategic themes helps assure they become accomplished. If this does not happen, a CNO can feel like they are a 1-person show. Burn out can happen, plus less gets accomplished.

9) Use Best Practices. Learn from others when you can.
As you are analyzing best practices for your facility, look at programs and structures first. This can be building better staffing business plans or best practice corporate nursing structures. Once your programs and structures are built, look at industry or regional best practices on standardization. This could include EHR documentation, policies and procedures, professional practice models, or shared decision making structures. And do not forget to keep things simple! A professional practice model for instance should be easy, simple and concise. Make it recognizable for your nursing staff so they can instantly identify it around their workplace and remember it when they provide care.

One pillar of your professional practice mod el can be Dr. Joanne Duffy’s Quality Caring Model. It is a study of human interaction and the role of cohesive teams in the achievement of healthcare outcomes. The Quality of Care Model aims to guide professional practice, reaffirm and expose the hidden work of nursing, and propose a research agenda that will provide evidence of the value of nursing.

8) Don’t be afraid to ask an Expert – either internal or external
The most significant internal experts are your Frontline clinical nurses! With less executive type experience they may not always articulate the information perfectly, but they know what is going on, have great ideas and learn quickly. For example, using this group for Peer Reviews can lead to good learnings. Other CNOs or their Assistant CNOs, are experts in your system who need to be engaged and bring different perspective to the issues. The same is true with their professional practice/education leaders.

An example of External Experts could be consultants that assist with Magnet preparation, training needs, web-platforms, or networking with other systems to discuss things like processes or nursing research. And don’t be shy with other professional practice leaders and clinicians, have a phone consultation with them to discuss your processes best practices!

7) Recruit frontline and leadership champions and keep getting their input
Nurse executives rely on shared decision making structures to gain input from the staff. For example, this is done at Texas Health Resources by making unit rounds and by leaders attending their Nursing Congress and other shared governance meetings. Input from the leaders is obtained through the Nursing Operations Council, and Nursing Executive Council. Each site CNO is expected to hold town hall meetings to receive input on strategic initiatives and programmatic input, and occasionally do videoconferences. Input can also be less formal, such as receiving direct information via rounding, email, and attendance at committee meetings.

6) A “YES” vote does not mean there is consensus or that it will get accomplished
Be clear that shared decision making does not mean you will always get your way. Sometimes reporting or direct reporting structures have to be changed. Sometimes you must work with selected entities that have a culture of independence, engage them when possible, when leading new initiatives. Be clear on what is negotiable and what is not negotiable.

5) Start small and build purposefully
Don’t try to build an organization too fast. Building purposefully can ensure managers understand the soft structure of teams and groups that need to be set up to get things done. As your management team grows, a matrix management style of leadership can be more dynamic as individuals with broader perspectives can deliver value and work together in an interconnected way. A matrix style of leadership can increase cooperation across the organization, can be more flexible, and individuals can be chosen according to the needs of the specific project.

4) Build the team with care
There is a difference when you inherit a team and you build a team. When you build a team you can make sure everyone’s values are in line. When the paradigm is changing, it can be more productive to help those unwilling or unable to change to find other opportunities. It is necessary to continually engage in building the team, and being clear about what the expectations are. When building your team, it is challenging at times to agree upon the best candidate. The popular candidate with staff may look very different than the popular candidate with the leadership and physician team. But cultural fit trumps team fit almost all the time, so be careful in candidate selection.

Each member should bring a unique strength to a team, so avoid over reliance on specific individuals in efforts to keep the whole team engaged. Some team members may express more enthusiasm, but be careful not to lean on them in excess.

3) Patience generally pays off
Large health system changes may take up to 3-5 years. When trying to implement a new culture, try to be respectful of other hospital locations cultures or unit norms as you slowly move toward the vision of one nursing service. There may be times as environment changes that you feel like you are starting all over again when building the underlying organizational culture. So stay patient!

2) Make it fun!
Do intentional fun activities and team building exercises. Vary your techniques to develop a party spirit and help the team to come together around common understandings. Here are some examples:
• Myers Briggs workshop
• Improvisation Workshop
• Dinner with AONE CEO
• Annual Christmas party team building – don’t be afraid to have an ugly sweater contest with your nurses!
• Annual/semiannual retreats for strategic planning
• Monthly celebration of achievements/recognitions at Nursing Executive Team meetings
• Informal after hours celebrations at system retreats and meetings – baseball games are fun and informal
• Cards and flowers are always appreciated on holidays and special events.

1) Timing is Everything!
Know when to introduce change, it is an art. Waiting until the right time has a significant impact on progress made over time. The Texas Health Resources system for instance waited for their centralization of Magnet and Pathways to Excellence efforts. These efforts were not ready for going public until 2016. Texas Health Resources benefited by starting small, and being patient while building a cohesive team.

The long-term vision always was to have each site obtain Pathway to Excellence or Magnet designation. This has recently been achieved and they have national presence around some programmatic areas. Now at Texas Health Resources, half of their CNOs are doctoral prepared, they are presenting at regional and national meetings, and they are participating in national level research and grants. It took about nine years to get to this esteemed level, but patience, timing, and building the right team got them there.

This is summarized from a presentation by Texas Health Resources at the AONE Annual Meeting, 2017. Contributors were Dr. Joan Shinkus Clark (SR VP of Nursing) and Dr. Paula Spears (VP of Professional Practice, Research in Magnet)

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