After reading chapters 7, 8, 9, 10 and the assigned readings students answer the questions in the Case Scenario and then 1 of the following questionsbelow (total of 2 questions for initial discussion due by Thursday, 5/18/23 by 11:59 pm and then two peer responses to Week 3 posting by Sunday, 5/21/23 by 11:59 pm.
Every student must answer Question 1 in relation to the Case Scenario and then students may choose which response they wish to answer to Question 2: either a OR b OR c (only 1 of these will be responded to). Note you MAY NOT USE the readings for this week as YOUR peer reviewed journals and references; you may include them as references but you must separately include two scholarly resources.
QUESTION #1: CASE SCENARIO
Healthcare Ethics: A Tale of Two Patients
RT is a 65-year-old who is a Medicare/Medicaid patient. This “dual eligible” status does not place them in a value-based contract. They are FFS for any hospital or provider who treats them. RT does not incur any out-of-pocket costs for medications. They have a primary care physician (PCP), but the PCP is private practice and is only loosely affiliated with several local hospitals. RT lives alone, is beginning to lose their sight, has no family close by, and has a case worker who runs their errands. RT has a history significant for chronic obstructive pulmonary disease (COPD) Gold Stage I, is on nebulizers at home as well as inhaled steroids, and goes on 3 L N/C of O2 at night. RT continues to smoke 1 pack per day and has for the last 50 years. No one pays any penalty if RT’s outcome metrics are poor. But Medicare/Medicaid incurs the cost of care, testing, medications, oxygen, transportation to repeat ED visits, and multiple hospital admissions as RT’s chronic conditions continue to deteriorate.
FS is a 67-year-old who has traditional Medicare. They have a PCP strongly affiliated with a local healthcare system. This healthcare system has contracted with Medicare to be in an “ACO.” This means that FS’s PCP and the health system are accountable for FS’s care and will only receive payment if FS stays out of the hospital and has good health outcomes. FS’s history is also significant for COPD Stage 1. FS is on nebulizers at home, takes an inhaled steroid, and uses 3 L O2 prn. They smoke 1 pack per day as well and are starting to have some significant deterioration of their COPD. If FS were to enter the hospital, the hospital will only receive a “bundled payment,” and if they re-enter the hospital in 90 days, the hospital will spend all the money they were given to care for FS just on this one episode. FS is also offered home care, respiratory therapy, and smoking cessation classes and coaching. FS says they cannot afford their inhaled steroid, so a pharmacist works with them to get the medications they need at a lower cost.
Discussion Question 1 (ALL STUDENTS MUST ANSWER THESE)
a. Would a bedside nurse know the difference in these two patients’ payor arrangements?
b. Should nursing be aware?
c. Should nursing continue to educate both patients on their disease?
d. What if these patients were on the same nursing unit? Would there be concern that these patients were being offered different levels of support at home going?
e. Clinically, what is the better way to care for the patient? Does that match the payor payment?
Discussion Question #2 (Answer one of the following below; students may choose they wish to answer)
a. Identify three common workarounds nurses in your practice area routinely do. Choose one and propose possible innovative solutions. Identify potential risks and benefits. Develop a plan for developing, implementing, and evaluating the innovation. Identify leadership styles, traits, and competencies that support or serve as barriers to innovation in care delivery.
POWERPOINTS TO ACCOMPANY
Nurse Leadership and Management
Foundations for Effective Administration
Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, FNAP, FAANP(H)
Celeste M. Alfes, DNP, MSN, MBA, RN, CNE, CHSE-A, FAAN
Editors
Chapter 8: Value-Based Contracting
Kristine Adams and Nicholas Engelhardt
© Springer Publishing Company, LLC.
1
Learning Objectives
• Demonstrate understanding of the history of healthcare payment structures and their effect on healthcare
delivery over the decades.
• Differentiate fee-for-service versus value-based care.
• Appraise how the different payment structures affect the care delivered and how nursing must adapt to
the different structures.
• Evaluate the different types of alternative payment programs available in the United States market.
• Investigate the differences between government payor programs and commercial programs.
© Springer Publishing Company, LLC.
2
Terminology
• Accountable care organization (ACO): A healthcare organization that incentivizes providers and health systems
by tracking identified quality metrics and reductions in the overall cost of care
• Population health: Value-based care reimbursement model focused on preventing disease and keeping patients
healthy
• Value-based contracting: Payment structure lies in overall patient outcomes, promoting quality and safety
• Bundled payment: Often 30, 60, or 90 days long and the goal is to manage the medical spend on that patient for
the set duration of time; set amount of payment for a patient’s condition; any dollars not spent are kept by the
healthcare system as revenue
• Care redesign: The systematic restructure of workflows to align with evidence-based best practices as well as
the continued monitoring of compliance of those best practices
© Springer Publishing Company, LLC.
3
Introduction: Value-Based Contracting
• Insurance payors and healthcare providers are on the same page: all want to keep populations healthy
and well
• Nurses historically have shied away from understanding healthcare finances…now is the time for nurses
to lean in
© Springer Publishing Company, LLC.
4
Healthcare History
• Financing of healthcare system began after WWII
• Franklin Delano Roosevelt was first to propose Economic Bill of Rights—right to adequate healthcare for all Americans
(did not pass Congress)
• 1965 Social Security Act Amendments established Centers for Medicare & Medicaid Services (CMS)
– Federal government is the largest healthcare consumer leading to major federal budget impact year after year
– Resulting in over utilization and increasing costs of healthcare delivery
• 1980s and 1990s healthcare costs began to soar
• Result of increased treatment/diagnostic technologies to treat cardiovascular disease and cancer
• The U.S. healthcare costs were 50% higher than another other country
• At the same time, the United States had lower life expectancy and higher infant mortality rate
(cont.)
© Springer Publishing Company, LLC.
5
Healthcare History (cont.)
• As a result: CMS developed different healthcare plans and established diagnostic-related groups (DRGs)
• Health Maintenance Organizations (HMOs)
• Prospective Payment Systems (PPSs)
• DRG—maximum dollar amount allotted for each diagnosis; left over dollars for caring for
the patient are kept by the hospital as profit—thus the push for meeting or shortening length of stay.
• As a result of readmission penalties, hospital began care model redesign, implementing utilization
management, scrutinize length of stay, care paths, pharmacy formularies, consolidation, and partnership
hospitals were all a result of the forced redesign
• In 2001, The Joint Commission introduced the Core Measures to drive quality of care
(cont.)
© Springer Publishing Company, LLC.
6
Healthcare History (cont.)
• Affordable Care Act (ACA): Americans had access to free-market healthcare exchange; individuals could
purchase healthcare plans independent of an employer at an affordable cost
• First attempt to improve healthcare access for Americans
• Primary care practices received government incentives to build services; money shifted away from
hospitals to primary care
• Continued quality outcome metrics have been placed on health systems, hospitals and primary care
practices
© Springer Publishing Company, LLC.
7
Fee-for-Service vs. Value-Based Care
• Fee-for-Service:
• Historically, the U.S. healthcare has been episodic:
– One gets sick or injured, seeks healthcare, gets better, goes on with life, and receives a bill; profit is earned on the
healthcare provider side
– More a patient is sick and seeks intervention, more bills are generated, more profit is generated
• Value-Based Care:
• Not concerned with payment around volume; payment structure based on overall patient outcomes, promoting quality and
safety
• Continuum of care must be seamlessly aligned and coordinated
• Dependent on care coordination: nurses, social workers, behavioral health caregivers, community health workers, and care
navigators
• Transitions of care out of hospital to care coordination in ambulatory/primary care space
• Drive ambulatory-based testing vs. inpatient testing to drive down costs
© Springer Publishing Company, LLC.
8
Strategies of Value-Based Care
• Correct patient attribution: Assignment of a provider responsible for all care and care coordination
• Closed network of services that provides care throughout the life span and continuum with minimal
leakage
• Goal for health system to define their network and keep patient care services within the network’s boundaries
• Data and analytics: Provides health system and providers a scorecard to track performance on any particular
payor contract
• Risk stratification data, so a provider knows where to put their resources and who needs intense care
coordination
• Identify patients at highest risk of increased utilization of healthcare services need to be wrapped in supportive services
• Health systems are incentivized to keep patients out of the hospital
• Wellness and prevention strategies for patients
• Contracting to improve overall patient health; disease prevention, slow progression of chronic disease (e.g., smoking
cessation, weight management, diabetes management, cancer screening)
• Patient activation: Encouraging patient to be active participant in their care
© Springer Publishing Company, LLC.
9
Care Management Structure
• Care Management (CM): Acts as an information conduit between inpatient and outpatient care teams, handing
off complex cases
• Clearly aligned inpatient and ambulatory CM/Care Coordination (CC) strategy
• Eliminates time spent finding resources for patients, as patients would not be handed off to those resources
• Utilization Management or Utilization Review (UM/UR): Primary responsibility is to package clinical
information, known as “reviews,” to send to the insurance provider; act as an extra set of eyes for the bedside
nursing teams regarding bundle inclusion or value-based programs within the commercial payor landscape
© Springer Publishing Company, LLC.
10
Additional Considerations of Value-Based Care
• Budgeting Strategy: Per member per month (PMPM) incentive = cost of care analysis
• Bundled payments based on 30-, 60-, or 90-days goal achievement.
• Revenue based on medical spend on the patient during the specific time
• Ensuring patient has wraparound services to keep them healthy at home will lead to capture of set reimbursement
dollar savings as revenue
• Analytics and key performance indicators—must align with data analytics and data science teams
• Information technology (IT) infrastructure, data reporting, system structure are essential to a successful
value-based care strategy
• Predictive analytics and outcomes—develop scorecards to track and trend performance, share widely
with team and leadership
© Springer Publishing Company, LLC.
11
Other Payment Programs—No “One Size Fits All”
• Comprehensive Primary Care Plus (CPC+) focused on outcomes: (1) access and continuity of care, (2) care
management, (3) comprehensiveness and coordination, (4) patient and caregiver engagement, and (5) planned
care and population health
• Chronic Disease Management
• Medicare Advantage “Part C”: Includes dental, vision, hearing, and fitness, which traditional Medicare does not
cover. Administered by commercial payors.
• Medicaid and the Children’s Health Insurance Program (CHIP): Ensures all children have access to
healthcare to age 18 regardless of income
• Medicaid Managed Care Organizations (MCO): CareSource, Aetna, Blue Cross/Blue Shield
• Commercial Plans: Purchased through employer or through Affordable Care Act
• High Deductible Plan: Low monthly fee, high copays
• Centers of Excellence: Patient allowed to access groups of providers at set locations based on quality
outcomes; out-of-pocket expenses are lower
© Springer Publishing Company, LLC.
12
Key Points
Payment reform promises to substitute value for volume, but value- and volume-based approaches typically
are implemented together. All payment methods have strengths and weaknesses, and how they affect the
behavior of healthcare providers depends on their operational design features and how they interact with
benefit design.
(Berenson et al., 2016, para. 1)
Berenson, R. A., Upadhyay, D., Delbanco, S. F., & Murray, R. (2016). A typology of benefit designs. Urban Institute Research Report. https://www.urban.org/research/publication/typology-payment-methods
© Springer Publishing Company, LLC.
13
Summary—Nurse Leaders Must…
• Acknowledge healthcare and payment landscape in the United States is a complex web of providers,
payors, and patients
• Become educated and savvy on how payment models work
• Educate themselves on value-based care and payment models to better advocate for patients
• Stay true to patient advocacy; help patients and front-line caregivers navigate
• Take an active role in policy and lawmaking at local, state, regional, national levels
© Springer Publishing Company, LLC.
14
POWERPOINTS TO ACCOMPANY
Nurse Leadership and Management
Foundations for Effective Administration
Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, FNAP, FAANP(H)
Celeste M. Alfes, DNP, MSN, MBA, RN, CNE, CHSE-A, FAAN
Editors
Chapter 9: Population and Community Health:
Leveraging Leadership and Empowering Nurses to
Understand and Positively Impact Social Determinants
of Health
Natalia Cineas and Donna Boyle Schwartz
© Springer Publishing Company, LLC.
1
Learning Objectives
• Demonstrate knowledge of the primary social determinants of health (SDOH) and the impact on
individual, community, and population health.
• Describe the connection between governmental policies and the impact on SDOH.
• Define the role nurses and nurse leaders play in advocacy and aligning nurse assessments with SDOH.
© Springer Publishing Company, LLC.
2
Introduction:
Population and Community Health
• Population health and community health
• Social determinants of health (SDOH)
• United States lagging behind, decline expected to continue
• Many international organizations
• Established goals
• Reducing health disparities or health inequities
• Various industry associations and analyses have indicated that these factors may be responsible for
more than 70%–80% of all health outcomes (Moody’s Analytics, 2017; Robert Wood Johnson Foundation,
2019)
Moody’s Analytics. (2017, December 14). The health of America report: Understanding health conditions across the U.S. BlueCross BlueShield Association. https://www.bcbs.com/the-health-of-america/reports/understanding-health-conditions-across-the-us
Robert Wood Johnson Foundation. (2019, February 1). Medicaid’s role in addressing social determinants of health. https://www.rwjf.org/en/library/research/2019/02/medicaid-s-role-in-addressing-social-determinants-of-health.html
© Springer Publishing Company, LLC.
3
Considering Social Determinants of Health
• Essential tenet: Driving force in promoting health and wellness
• Nurses and leaders play vital role in advocating
• Need to incorporate into practice to achieve improved overall health
• Population growth
• Affordable Care Act 2010—Internal Revenue Service (IRS) requirement to conduct community health
needs assessment
• Healthy People 2020 and Healthy People 2030—updates to codify the “place-cased” framework
© Springer Publishing Company, LLC.
4
Neighborhood and Built Environment
• Impact: Individual, community, and population health
• Flint, Michigan’s drinking water
• Outbreak Legionnaires’ disease
• 2,337 communities in 49 states: chemical contamination from perfluorooctane sulfonate and perfluorooctanoic acid
(PFAS/PFOA)
• Where people live, work, and play
• Environmental conditions
• Quality of housing
• Crime and violence
• Access to foods that supply healthy eating patterns
© Springer Publishing Company, LLC.
5
Environmental Conditions
• Climate and climate change
• Increasing frequency and severity
• 2020—second highest temperature since 1880; 10th warmest since 2005
• Water, soil and air quality
• Urban—air pollution
• Rural—family farming, water contamination
• Minorities, poverty, and economically disadvantaged—suffer adverse health outcomes
© Springer Publishing Company, LLC.
6
Social Conditions
• Quality of housing
• Crime and violence
• Access to food that supports healthy eating patterns
• Social and community context
• Discrimination
• Gender discrimination
• LGBTQ+
• Age and disability discrimination
• Incarceration
© Springer Publishing Company, LLC.
7
Economic Conditions
• Civic participation
• Social cohesion
• Economic stability
• Poverty
• Quality of housing
• Employment
• Food insecurity
• Housing instability
© Springer Publishing Company, LLC.
8
Education Conditions
• Education
• Language and literacy
• Early childhood education and development
• High school graduation
• Enrollment in higher education
© Springer Publishing Company, LLC.
9
Health and Healthcare Conditions
• Health and healthcare
• Access to healthcare
• Access to primary care
• Health literacy
• COVID-19 and COVID-19 vaccine hesitancy
© Springer Publishing Company, LLC.
10
Key Points and Summary
• Nurses and leaders are essential to achieve broad population and community health goals
• Vitally important to understand and address SDOH
• Nurses are well positioned
• Nurses need to use their clinical skills
• Have greater responsibility
• Need to be better prepared in education and clinical practice to address and mitigate the impact of SDOH
© Springer Publishing Company, LLC.
11
POWERPOINTS TO ACCOMPANY
Nurse Leadership and Management
Foundations for Effective Administration
Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, FNAP, FAANP(H)
Celeste M. Alfes, DNP, MSN, MBA, RN, CNE, CHSE-A, FAAN
Editors
Chapter 10: Telehealth
Noreen B. Brennan
© Springer Publishing Company, LLC.
1
Learning Objectives
• Describe the historical development of telehealth.
• Differentiate between the variety of telehealth technologies.
• Assess implementation components of a telehealth program, from the patient, provider, and
organizational perspectives.
• Investigate the legal, ethical, and regulatory issues associated with telehealth programs.
© Springer Publishing Company, LLC.
2
Terminology and Introduction
• Telehealth system: A system of electronic communications
• Individual remote care: Intensive care can be monitored from global regions
• Significant part of current and future healthcare delivery
• Rapid advancements
© Springer Publishing Company, LLC.
3
History
• Advent of telephone
• Radio
• Closed-circuit TV
• Biometrical data
• Costly
• Difficult integration
• Federal funding
• Not a viable option for medicine
• Used by military in 1980s
• Development of wearable technology
© Springer Publishing Company, LLC.
4
Use of Telehealth
• Various uses
•
•
•
•
Clinical care
Personal healthcare
Video conferencing
Education
• Four types
•
•
•
•
Live videoconferencing (synchronous)
Store and forward (asynchronous)
Remote patient monitoring (RPM)
Mobile health (MHEALTH)
© Springer Publishing Company, LLC.
5
Evidence-Based Practice and Application
• COVID-19 pandemic: Changed overnight from in-person to virtual
• Positive outcomes in relation to mortality
• Remote monitoring for chronic conditions
• Psychotherapy
• Communication/counseling for chronic conditions
• Increase in published articles
• 2020: 17,200 articles
• Previous 3 years: only 300 articles
• Expanding patient groups: oncology, pediatrics, gastroenterology, occupational therapy
© Springer Publishing Company, LLC.
6
Communications
• Used for communication between healthcare providers
• Several tools
• Electronic medical records (EMRs)
• E-consults
• Social media platforms
• Email
• Secure texting
• Instant messaging
• Push notifications
• Video
• Phone calls
• Emergence of standards for network etiquette, “netiquette”
© Springer Publishing Company, LLC.
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Key Points and Summary
• Telehealth is not a new concept
• Distinct types
• Established competencies
• Telehealth is an adjunct
• Provides changes to the clinicians’ workflow
• Access and connectivity
• Will need experience with large data sets so social determinates can be better addressed
© Springer Publishing Company, LLC.
8
POWERPOINTS TO ACCOMPANY
Nurse Leadership and Management
Foundations for Effective Administration
Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, FNAP, FAANP(H)
Celeste M. Alfes, DNP, MSN, MBA, RN, CNE, CHSE-A, FAAN
Editors
Chapter 11: Innovation
Cole Edmonson and Tim Raderstorf
© Springer Publishing Company, LLC.
1
Learning Objectives
• Demonstrate an understanding of the Innovation Continuum and how to develop a culture of innovation.
• Apply the concept of Innovation to healthcare and the nursing profession.
• Critique the core competencies of innovation as they relate to the role of nurse leaders and nurse
executives.
• Investigate how different leadership styles and system structures influence innovation.
© Springer Publishing Company, LLC.
2
Introduction: Innovation
• Deep historical roots—1800s Florence Nightingale
• Emerging global disease trends, pandemic challenges fuel innovation
• Nurse well positioned to innovate
• Nurse executives and nurse leaders have a key responsibility for innovation
• Nurse leader and executive roles and responsibilities themselves are innovative
© Springer Publishing Company, LLC.
3
Defining Innovation
• The Novation Dynamic
•
•
•
•
•
Maximize one’s impact, recognizing changes needed
Making strategic changes to existing solutions
Leaders determine change—renovations or exnovation—and next steps
Assess the gaps: Product, service, or outdated solution
Exnovation is most challenging aspect of Novation Continuum
© Springer Publishing Company, LLC.
4
Difference Between Innovation and Entrepreneurship
• Innovation and entrepreneurship (I&E) are used frequently together and showcase connectivity
• Key distinction is the intent of the innovator
• Innovation is the process of implementing a new product, services, solution
• Entrepreneurship is the process of implementing new product, services, solutions, creating new value
• Head-to-head innovation
• Intrapreneurship
© Springer Publishing Company, LLC.
5
Innovation Competencies
• Recognize opportunity
• Understand healthcare system
• Convey a compelling vision; seeing the future
• Leverage resources (“bootstrapping”)
• Maintain focus/adapt
• Risk management/mitigation
• Resilience
• Creative problem-solving, imagination
• Interdisciplinary teamwork and collaboration
• Guerilla skills/unconventional approaches
• Assess opportunity
• Design thinking
• Build and use networks
• Change management
• Self-efficacy/confidence
• Cross-disciplinary knowledge
• Tenacity and perseverance
• Information management
• Behavioral economics
(cont.)
© Springer Publishing Company, LLC.
6
Innovation Competencies (cont.)
• Assessment
• Diagnose
• Plan
• Implement
• Evaluate
• Moving from resilience to ambition
• Cultures of innovation
© Springer Publishing Company, LLC.
7
Leadership in Innovation Cultures
• Same traits for leading evidence-based practice and research
• Need to be curious and reward curiosity
• Communication and listening
• Transformational and collaborative leadership styles replace those based on hierarchy and transaction
• Partnering with academic organizations to surface opportunities, connect with interprofessional partners
© Springer Publishing Company, LLC.
8
Structures of Innovation
• Incentives for clinicians, managers, and clinician-leaders
• Performance goals for nurse managers and executive leaders
• Educational programs
• Policies
• Job descriptions
• Calls to action
• Mentoring and coaching
• Partnerships
• Innovation centers
© Springer Publishing Company, LLC.
9
Sustaining Innovation
• Difficult and challenging process
• Need to create cultures of innovation
• Organizational infrastructures are the foundation of sustainability
© Springer Publishing Company, LLC.
10
Key Points and Summary
• Innovation is created and led by individuals, not organizations or policy
• Nurse are natural innovators, long history of changing the world
• Imperative nurses stretch their comfort zone
• Your challenge as a leader
• Review organization’s mission, vision, and values and your job description to make a plan
• Learn from mistakes, welcome mentoring
© Springer Publishing Company, LLC.
11
Since January 2020 Elsevier has created a COVID-19 resource centre with
free information in English and Mandarin on the novel coronavirus COVID19. The COVID-19 resource centre is hosted on Elsevier Connect, the
company’s public news and information website.
Elsevier hereby grants permission to make all its COVID-19-related
research that is available on the COVID-19 resource centre – including this
research content – immediately available in PubMed Central and other
publicly funded repositories, such as the WHO COVID database with rights
for unrestricted research re-use and analyses in any form or by any means
with acknowledgement of the original source. These permissions are
granted for free by Elsevier for as long as the COVID-19 resource centre
remains active.
Nursing Leadership and COVID-19:
Defining the Shadows and Leading
Ahead of the Data
Joshua A. Wymer, MSPM, MA, MSN, RN, CNOR, CSSM, RN-BC, NEA-BC,
CPHIMS, FACHE,
Christopher H. Stucky, PhD, RN, CNOR, CSSM, CNAMB, RN-BC, NEA-BC, and
Marla J. De Jong, PhD, RN, CCNS, FAAN
The COVID-19 pandemic overwhelmed health care systems and exposed major gaps
in preparedness and response plans. The crisis challenged nurse leaders to develop
and implement novel care delivery plans while preventing disease transmission to
patients and staff. COVID-19 required nurse leaders to make decisions in an environment of conflicting data and directives. The authors share essential nurse leader
competencies vital to the development and support of thriving nurse leaders. As
crises persist and future challenges arise, nurse leaders can leverage these essential
competencies to successfully drive engagement, lead ahead of consensus, and
define the shadows of limited, incomplete, and conflicting data.
T
he coronavirus disease 2019 (COVID-19)
pandemic overwhelmed health systems globally
and compelled leaders to restructure health care
operations and services to sustain the regular cadence
of sick and injured patients and meet additional care
requirements during critical surges of patients with
COVID-19.1 The pandemic response caused an unprecedented global upheaval of routine care and
standard procedures. The disruptions included socially
distanced work spaces, cancellation of elective surgeries
and screening procedures, expansion of telehealth
across outpatient services, restricting inpatient visitation privileges, implementation of universal personal
protective equipment (PPE), expansion of patient care
into previously vacant or nontraditional spaces,
dissemination of new patient care techniques (e.g.,
proning), staffing temporary external locations,
changing patient flow patterns, assigning staff to unfamiliar work centers or partner facilities, communicating differently with patients’ family members, and
implementing new testing techniques.2
Although federal and state laws mandate that
hospitals develop and implement emergency response
plans regarding natural and man-made disasters, many
hospitals and healthcare systems were woefully unprepared for the pandemic response. The domino effect of disease-infected patients and health care workers
resulted in staffing, equipment (e.g., beds, ventilators,
www.nurseleader.com
oxygen cylinders), and PPE shortages while also
reducing access to care for noninfected patients.3
The pandemic also created an extraordinary
period of responsive innovation and agility across
health care and the nursing profession. Nursing proved
a particularly valuable contributor to the multidisciplinary health care team during the pandemic crisis
because infection control, team-based patient care, and
health surveillance are roles ideally suited to the profession’s strengths. Federal and state policymakers
temporarily removed long-established barriers limiting
registered nurse mobility and eased regulations to
address staffing shortages and aid the pandemic
KEY POINTS
Nurse leaders often make decisions in an
environment of conflicting data and
directives.
Nurse leaders must harness respect and
goodwill while overcoming current
challenges.
Nurse leaders must develop and mature the
skills necessary to quickly identify and
effectively respond to crises.
October 2021
483
response, including those governing full practice authority for advanced practice registered nurses
(APRNs).4 Through professional initiative and
answering the challenge of the pandemic, nursing
leadership validated their role as thought leaders,
operational innovators, and trusted partners of other
engaged disciplines.5
Nurse leaders contributed to many original solutions that limited the spread of disease and aided the
pandemic response.6 Nursing leadership delivered
rapid changes across health systems and adapted strategic plans and operational contingencies to address
changing local and national policies, emerging data
trends, scientific discoveries, and surge capacity
requirements.
Critical to the profession’s ability to improve clinical practices based on evidence, nursing leadership
quickly adapted to the evolving crisis by analyzing
evidence in real-time and monitoring for data trends.
Further testing both epidemiological and organizational agility, continually shifting data and directives
forced nurse leaders to make timely, calculated decisions affecting the health and safety of patients and
staff, while seeking to define ambiguous themes and
unknown variables across multiple sources of limited,
incomplete, and conflicting data.
DEFINING THE CHALLENGE
The COVID-19 pandemic quickly evolved into a oncein-a-lifetime global health challenge even as the United
States grappled with social challenges such as unemployment, food insecurity, homelessness, xenophobia,
health disparities, and higher rates of infection, hospitalization, and death for Black, Asian, Native American, and Hispanic persons.1 As the nursing profession
seeks to define these contemporary challenges and the
many unknowns, empowered nurse leaders can
leverage the nursing process, evidence-based practice,
and professional experience knowing that those tools
have always informed the profession’s ability to deliver
positive change.7
A FOUNDATION FOR SUCCESS
The nursing profession has historically represented a
critical bridge between the science and the art of health
care, and nurse leaders continue to deliver when
challenges are the most daunting and the least defined.
Through the first 2 decades of this new millennium, the
nurse leader role has become even more vital as the
frenetic pace of innovation and change challenges
governments, health care systems, and communities.8
Nursing has a proud history of service during crises,
including SARS, H1N1, MERS, Ebola, and Zika.9
Today’s challenges, including COVID-19, are no
different, and nurse leaders remain uniquely positioned
and equipped to lead ahead of the data, both now and
in the future. The calling to care for all and relentlessly
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October 2021
advocate for the most vulnerable continues to lighten
the physical burden of illness for patients while
bridging many divides within communities.
As identified by the American Nurses Association
(ANA), foundational leadership competencies include
flexibility and the capacity to adapt previously established plans to changing external pressures.10
Responsive nurse leaders must develop and mature
the skills necessary to quickly identify and effectively
respond to external forces threatening health care delivery in their communities. These threats may include
health crises, political processes, and other catastrophic
or emergent events.
DELIVERING ON THE PROMISE
Without regard for obstacle or challenge, the nursing
profession would benefit from regular recommitment
to professional and ethical standards that serve as
foundational support for timely and effective decisionmaking.11 Because leadership is fundamental to
advancing the nursing profession,12 nurse leaders have
a professional obligation to develop their teams, readiness policies, and contingency procedures to support
crisis and disaster readiness and management.
Huston13 identified 8 essential nurse leader competencies vital to developing prepared nurse leaders
who can meet current challenges. Nurse leaders
develop their people, guide their organizations, and
build resilience through training, equipping, and preparing their teams for contingencies. Huston’s 8
essential competencies are particularly relevant
considering the current pandemic. Briefly, we expand
on the competencies below and use COVID-19 to
provide context for current and future pandemics,
natural disasters, and terrorism.
Having a Global Perspective or Mindset
Regarding Health Care and Professional
Nursing Issues
A global perspective enhances the nurse leader’s ability
to anticipate change and succeed as a healthcare
champion. Nurse leaders with a global perspective
were aware of the mounting evidence of a potential
pandemic, and their organizations benefitted from an
early shift to face the new challenge. A global
perspective informs contingency planning, and these
leaders were equipped to more effectively respond to
shortages in PPE, respiratory adjuncts, ventilators, and
staff.
A global mindset also empowers nurse leaders to
acknowledge the diverse experiences and opinions of
others alongside recognition of their own biases.13
Boldly pursuing alternative points of view creates a
posture and environment conducive to success. Previously unreachable consensus and unrecognized opportunities become attainable through the integration of
disparate interests and competing perspectives.14
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As society grapples with a crisis of conscience
around injustice and bias, nurse leaders are presented
with a timely reminder to further enhance a posture of
active support for diversity, inclusion, and social justice
while addressing social determinates of health. Persaud15 identifies nurse leaders as standard-bearers for
inclusion and diversity across organizations with an
ethical obligation to build and support such
environments.
Acquiring Technology Skills to Facilitate
Mobility and Portability of Relationships,
Interactions, and Operational Processes
Modern health care and nursing services are driven by
perpetually evolving technology. Nurse leaders share
unique perspectives and insights that can influence
their organization’s acquisition, integration, and optimization of technology. System challenges, staffing
contingencies, and environment of care considerations
driven by COVID-19 have only accelerated the evolution of health care.
With the exponential growth of remote work and
telehealth, nurse leaders are increasingly contributing
to the business of health care through oversight of
remote work policies, development of connectivity requirements, standardization of collaboration resources,
and participation in patient privacy and data security
governance.16 Selecting the right technology and validating existing infrastructure is seeing renewed
emphasis as an integral component of the nurse leader
role.
It is unlikely that nurse leaders will see a significant
drawdown in these new responsibilities in a postCOVID-19 environment. Opportunities to empower
patients, improve access to care, facilitate research,
and optimize outcomes will continue to drive nurse
leader engagement, relationships, and operational
processes.17
Developing Expert Decision-Making Skills
Rooted in Empirical Science
The pandemic has forced nurse leaders to recalibrate
strategic plans and reorganize clinical operations
without discrete data or a roadmap to guide those
decisions. As the crises evolve, advanced decisionmaking expertise empowers and equips nurse leaders
to develop and implement innovative solutions to
address present requirements while establishing the
framework for future success.18
Well-honed decision-making skills are most effectively developed in a supportive and change-welcoming
environment defined by open communication and
collaborative relationships.19 For many, the spectrum of
current challenges have proven “career-defining” for
the professional development of nurse leaders through
professional acceptance as well-equipped and fully integrated peer collaborators across multidisciplinary
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organizations and agencies confronted by a poorly
defined global crisis.20
Creating Organizational Cultures That
Permeate Health Care Quality and Safety
Many methods can help build a productive and inclusive professional culture, but successful nurse
leaders never miss an opportunity to elevate their
staff as patient advocates and quality champions.
As COVID-19 continues to impact communities,
nurse leaders can consult with professional and
community partners to acquire, track, identify,
isolate, evaluate, analyze, document, and pursue
those variables and concerns shaping their local care
environment.21 As respected collaborators across
multidisciplinary teams, nurse leaders can contribute
to enhanced quality and safety structures within their
organizations.22
Recognizing Opportunities to Appropriately
Intervene in Political Processes
Nurse leaders are unique positioned to intervene and
shape public discourse and healthcare policy on behalf
of their patients and communities. As highly respected
health care advocates, the most trusted profession, the
largest health care profession, and the professional
bridge between health care policy and health care
delivery, no group is more equipped to appropriately
intervene in political processes.23 Nickitas24 argues that
nurse leaders cannot allow the current climate of political division to affect the profession’s response to
COVID-19.
As the country reels from the COVID-19
pandemic, natural disasters, and social disruption that
defined 2020 to 2021, nurse leaders must drive political
awareness and policy development, addressing threats
to healthcare professionals, patients, and communities.24 Political education, active psychological
engagement, and collective influence are known factors
that enhance nursing influence on policy and politics.25
Even in a pandemic environment, nurse leaders must
own political advocacy in pursuit of good policy. Nurse
leaders remain supremely qualified to identify gaps
between current policy and health-related requirements through integrated knowledge of community resources, needs, and disparities.26
Possessing Highly Developed Collaborative and
Team-Building Skills
Highly collaborative, team-building nurse leaders
establish healthy work environments built around
standards and expectations for professional communication, true collaboration, effective decision-making,
appropriate staffing, meaningful recognition, and
authentic leadership.27 Engaged employees become
active and contributing team members achieving
shared values, common purpose, and cooperative
October 2021
485
work.13 Meyer28 brilliantly highlights the nurse leader’s
obligation to educate their staff that agreement and
support are not codependent concepts. Huston13 also
identifies the critical role of collaboration as empowering for leaders of highly educated, multidisciplinary
professionals.
Balancing Leadership Authenticity and
Performance Expectations
The ever-changing health care environment has made
communication even more vital as nurse leaders seek
to drive performance, enhance safety, impact quality,
and deliver better outcomes. The dynamic nature of
current challenges has further altered and stressed
communication between nurse leaders and staff during
a time when timely and effective engagement is most
vital.
Authenticity is another tool that can serve as a
bridge to success for nurse leadership establishing
new expectations while seeking to limit the burden on
their overtasked staff. The principles of authentic
leadership include the unique characteristics of selfawareness, relationship transparency, and having an
internalized moral perspective. Authenticity can be
delivered by nurse leadership by focusing on one’s
own development, knowing oneself, and demonstrating transparency in all relationships.29 These efforts may serve to empower the individual staff
member and enhance team performance as the nurse
leader communicates genuine interest and care for
their teams.29
Envisioning and Proactively Adapting to a
Health Care System Characterized by Rapid
Change and Chaos
Today’s environment has reinforced the critical role of
nurse leaders in assessing, developing, and enhancing
their organization’s capacity for change. The unique
demands of strategic leadership, operational excellence, and relationship management dictate a decisive
yet agile approach that leans into and owns every
challenge. In this way, nursing leadership models the
nursing profession’s well-established capacity to sustain
and thrive through chaos and change.30
The current nursing leadership experience, defined
by rapid change and chaos, has represented a uniquely
powerful opportunity to “stress test” our infrastructures
and systems in very real and practical ways.31 The
nursing profession and nurse leaders were at the forefront of the pandemic through leadership of response
teams, improving access to care through expanded
telehealth, shaping new policies and procedures, and
many other ways. In the face of disruptions to care,
access, and utilization, nursing leadership remains a
vital link in building and sustaining resilience through
enhanced resources and support to health care
teams.32
486
October 2021
LOOKING TO THE FUTURE
Nursing leadership remains a lynchpin for effective
multidisciplinary engagement with sustained commitment to patient and community advocacy. Nurse
leaders across academia, clinical practice, and industry
represent the best of a profoundly gifted and dynamic
group, which is only increasing in size and influence.
The continuous evolution of the profession and its
powerful role in communities, nations, and the world is
based in the diversity of the professionals, specializations, and unique roles that comprise its ranks.
The nursing profession represents a critical link
between science and the art of healthcare. The calling
to care for all and relentlessly advocate for the most
vulnerable continues to lighten patients’ physical
burden while fostering greater respect, humility, and
understanding. Nurse leaders must harness respect
and goodwill in pursuit of those challenges that are
without solutions and those questions that are without
answers.
As nursing leadership develops strong, sustained,
and mutually enriching relationships across teams,
departments, and organizations, individual leaders will
continue to serve as vital partners as communities
seeking to heal division and mistrust. The nursing
profession’s focus on service to others and the betterment of all will empower these efforts of renewal and
rebuilding as the nursing profession and nursing leadership demonstrate their unique ability to deliver on
trust.
Leveraging a heritage of resilience, innovation, and
scientific inquiry, nursing leadership is uniquely
equipped to guide organizations through tumultuous
times. The multidisciplinary strength of the nursing
profession has thrust nurse leaders into key roles across
the full spectrum of our nation’s response to the current
crises. Nursing leadership must own and build on the
profession’s proud legacy of untiring and unwavering
passion for caring and excellence in the service of
others.
CONCLUSION
The nursing profession arose out of the recognition
that humanity could do better and could be better. In
that spirit, nursing leadership is equipped with the
knowledge, experience, and skills to deliver when the
data and the science are poorly defined. Nurse leaders
have delivered excellence in health and caring for
humanity many times in the past, and the profession
will continue this proud legacy.
A unique blend of moral, ethical, and legal obligations serve to empower nursing leadership to elevate
teams and transcend contemporary challenges. Today’s
leadership environment includes compelling opportunities to drive innovation, enhance organizations, serve
communities, and deliver on a remarkable history of
resilience, integrity, and achievement while redesigning
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health care delivery systems in an image that is more
equitable, adaptable, and resilient.
The guideposts from the past empower nursing
leadership to define the shadows and pave a bold path
for tomorrow’s nursing professionals. Individual nurse
leaders will continue to find success in conquering
contemporary challenges and building more resilient
teams and systems while satisfying their professional
obligations of service and caring. The profound
connection that nursing leadership has built, and
continues to build within their organizations and
communities, will enhance the nursing profession’s
future achievements, growth, influence, and impact for
patients and communities.
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Joshua A. Wymer, MSPM, MA, MSN, RN, CNOR, CSSM,
RN-BC, NEA-BC, CPHIMS, FACHE is Chief Nursing
Informatics Officer at the Naval Medical Center San
Diego, in San Diego, California. He can be reached at
joshua.a.wymer.mil@mail.mil. Christopher H. Stucky,
PhD, RN, CNOR, CSSM, CNAMB, RN-BC, NEA-BC, is
Deputy Chief of Research and Nurse Scientist at Center
for Nursing Science and Clinical Inquiry, Womack Army
Medical Center, in Fort Bragg, North Carolina. Marla J.
De Jong, PhD, RN, CCNS, FAAN, is Dean, Professor, and
Louis H. Peery Presidential Endowed Chair at the
University of Utah College of Nursing in Salt Lake City,
Utah.
Note: The authors received no funding to write this
manuscript. The authors have no conflicts of interest
to declare. The views expressed are solely those of
the authors and do not reflect the official policy or
October 2021
487
position of the US Army, US Air Force, US Navy, the
Department of Defense, or the US Government.
488
October 2021
1541-4612/2021/$ See front matter
Published by Elsevier.
https://doi.org/10.1016/j.mnl.2021.06.004
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