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Letter to the Editor

Registered Nurses Leading Innovative Changes

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Timothy W. Thomas, BSN, RN
Patricia C. Seifert, MSN, RN, CNOR, FAAN
Jane Clare Joyner, JD, MSN, RN

Abstract

As innovators, all registered nurses (RNs) act as agents of change to drive processes and policy and leverage technology to prove better, more affordable care for individuals and the community. The authors consider examples of RNs leading innovative ideas and practices to create new knowledge; develop healthcare policies and practices; improve the quality of care; and advance health information technology. This article describes a number of key innovation goals identified by the American Nurses Association Professional Issues Panel, Barriers to RN Scope of Practice, discusses relevant literature related to overcoming barriers to innovation, and identifies recommendations for leading innovative change to achieve innovation goals.

Citation: Thomas, T.W., Seifert, P.C., Joyner, J.C., (September 30, 2016) "Registered Nurses Leading Innovative Changes" OJIN: The Online Journal of Issues in Nursing Vol. 21, No. 3, Manuscript 3.

DOI: 10.3912/OJIN.Vol21No03Man03

Key Words: advocacy, change, communication, coordination, critical thinking, delegation, education, financial skills, innovation, innovator, leader, National Quality Strategy, nurse, processes, policy, quality improvement, resiliency, simulation, technology, training, triple Aim

The American Nurses Association (ANA) Professional Issues Panel, Barriers to RN Scope of Practice (SOP Panel), was established to identify and clarify barriers to registered nurses (RNs) practicing to the full extent of their education, experience, and scope of practice (SOP) as determined by the relevant nurse practice act. The Panel's Steering Committee identified barriers that prevent RNs from working to the full extent of their education and training, and explored the basis and developed recommendations to address these barriers. Panel members organized the findings based on four key roles of RNs in the healthcare delivery system: RN as professional, RN as advocate, RN as innovator, and RN as collaborative leader.

Separate articles in this OJIN topic have addressed each role; this article explores the theme that as innovators, all registered nurses (RNs) act as agents of change in driving processes and policy and leveraging technology to advance the three aims of the National Quality Strategy (IHI, n.d.): “(1) better experiences with health care, (2) better population health, and (3) lower costs” (Mason et al, 2015, page 549). The authors consider examples of RNs leading innovative ideas and practices to create new knowledge, develop healthcare policies and practices, improve the quality of care, and advance health information technology. The article describes a number of key innovation goals identified by the American Nurses Association Professional Issues Panel, Barriers to RN Scope of Practice, discusses relevant literature related to overcoming barriers to innovation, and identifies recommendations for leading innovative change to achieve innovation goals.

Registered Nurses as Leaders of Innovative Ideas

Within the nursing realm, the ANA Scope and Standards of Practice helps frame the perspective from which nursing innovation takes place... Within the nursing realm, the ANA Scope and Standards of Practice (ANA, 2015a) helps frame the perspective from which nursing innovation takes place:

Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations. (p. 1)

The recently updated ANA scope and standards of practice document calls for all RNs to be leaders within the profession, working to influence policies and encourage innovation (ANA, 2015a).

This section will examine the innovative ideas and practices of nurses who are creating new knowledge, developing healthcare policies and practices, improving the quality of care, and advancing health information technologies. Ideas and achievements of these nurse innovators drive the development of products, processes and policies to improve healthcare.

Innovation
 Critical elements of the innovation process encompass the creativity of the team or individual... Innovation has been described as “the intentional introduction and application within a role, group, or organization, of ideas, processes, products or procedures, new to the relevant unit of adoption, designed to significantly benefit the individual, the group, or wider society" (Omachonu & Einspruch, 2010, p 20). Critical elements of the innovation process encompass the creativity of the team or individual, the innovation itself, and the environment that developed, and sustained the innovation (Blakeney, Carlton, McCarthy, & Coakley, 2009).

The Agency for Healthcare Research and Quality (AHRQ) defines innovation as “a new way of doing things to improve healthcare delivery” (Agency for Healthcare Research and Quality [AHRQ], 2008). According to the AHRQ, innovations may be processes, systems, business models, or other “new” products or services. The Agency for Healthcare Research and Quality Guide to Adopting Innovations (AHRQ, 2008) identifies helpful questions to ask about innovations and suggests ways to make evidence-based decisions about the appropriateness and the potential efficacy of a particular innovation (see Table 1).

Table 1. AHRQ Guide to Innovation: Questions to Consider

  1. Does the innovation fit?
    • What is the innovation?
    • Does it further our goals?
    • Is it compatible with our organization?
  1. Should we do it here?
    • What are the potential benefits? Costs?
    • Can we build a business case?
    • What are the risks?
  1. Can we do it here?
    • Are we ready for this change?
    • What changes will we have to make?
    • Do we have the ingredients for success?
  1. How will we do it here?
    • How will we measure the impact of the innovation?
    • Can we try the innovation first?
    • How will we implement the innovation?

Agency for Healthcare Research and Quality (2008). Public Domain.

Creation of New Knowledge
Innovative efforts in the healthcare system are often focused on furthering what is described as the Institute for Healthcare Improvement (IHI, n.d.) Triple Aim: 1) improving the patient experience of care (including quality and satisfaction); 2) improving the health of populations; and 3) reducing the per capita cost of healthcare. Berwick, Nolan, and Whittington (2008) emphasized the importance of simultaneously working toward all three of these aims to effectively reform the United States (U.S.) healthcare system. Stiefel and Nolan (2012) described various frameworks to measure organizational efforts to further the IHI Triple Aim.

Aims of the National Quality Strategy (NQS), to provide better, more affordable care for individuals and the community, build upon the IHI Triple Aim. The NQS is described as a “catalyst and a compass for stakeholders to provide better, more affordable care for the individual and the community.” (U.S. Department of Health and Human Services, 2016, p. 26). Leaders in the nursing profession have made efforts to protect, promote, optimize and advocate for the health of individuals, families, groups, communities, and populations (ANA, 2015a), align well with the goals of the NQS and the Triple Aim.

Innovations in Primary Care
Innovative research is helping us to identify how skills and knowledge of RNs can be leveraged to improve healthcare delivery in primary care. Innovative research is helping us to identify how skills and knowledge of RNs can be leveraged to improve healthcare delivery in primary care. Smolowitz, et al. (2015) described a number of practices that deliver primary care in team based settings and use RNs to the full extent of licensure and SOP in functions related to practice operations, management of chronic disease, and episodic and preventive care. Pittman and Forrest (2015) researched the shifting roles of RNs in Accountable Care Organizations (ACOs), a delivery model where a group of healthcare providers work collaboratively and are collectively accountable for the cost and quality of the care they provide. Pittman and Forrest (2015) reported that ACOs are using RNs in new and enhanced roles and they suggested that administrators are motivated to use healthcare providers to the full extent of their education and training when responsibility for the risk of providing care shifts from payers to providers.

...administrators are motivated to use healthcare providers to the full extent of their education and training when responsibility for the risk of providing care shifts from payers to providers. These and other redesigned healthcare delivery models offer opportunities for nurses to work in new and innovative ways to impact population health initiatives; transitional care and care coordination; interprofessional collaboration; and patient and family engagement (Fraher, Spetz, & Naylor, 2015). To accommodate evolving and expanding roles, RNs must develop expertise to use data and health information technology (HIT) to further evidence-based practice; nursing education models must be adapted to prepare nurses for these new roles; and numerous policy and regulatory changes will be necessary (Fraher et al., 2015). All of these roles offer opportunities for innovation. The expanded and enhanced roles identified by Pittman and Forrest (2015), Smolowitz et al. (2015), and Fraher et al. (2015) are further delineated in Table 2.

Table 2. Expanded and Enhanced Roles for RNs

Examples of Roles, Functions and Opportunities

Eight RN roles in Pioneer Accountable Care Organizations

Pittman and Forrest (2015, p. 556-557)

  • Enhanced RN roles in primary care
  • Substitution of RNs for providers for certain acute conditions in primary care
  • Delegation of tasks to licensed practical nurses and medical assistants
  • Increased in demand for RNs in care coordination roles
  • Transfer of services from hospitals to primary care and from skilled nursing facilities to home care
  • Relocation of nurses from hospitals to primary care clinics
  • Use of nurses as liaison care coordinator across settings
  • Partnerships between nurses in primary care and hospitals

Nine RN roles in primary healthcare

Smolowitz, et al. (2015, p. 133)

  • Delegated care for episodic illness management
  • Telephone triage
  • Medication reconciliation
  • Health coaching
  • Assessment and documentation of health status
  • Intensive care/case management with a focus on chronic illness
  • Hospital transition management
  • Practice management and staff supervision
  • Quality improvement and team leadership

RN roles and opportunities in a transformed healthcare system

Fraher et al. (2015, p.  2-5)

  • “Boundary Spanner” connecting patients with resources in the community
  • Public Health Nurses and Population health
  • Long-term services and support for complex older adults and their caregivers
  • Care coordination and transitional care
  • Use of data, evidence, and other performance improvements skills
  • Interprofessional collaboration

Table 2 extrapolated from Pittman and Forrest (2015); Smolowitz et al. (2015); Fraher et al., (2015).

Exemplars of Nursing Innovation: Edge Runners
...nurse innovators are working to improve outcomes and the patient experience by reimagining and redesigning healthcare and developing innovative models of care. The American Academy of Nursing (AAN) highlights nurses involved in innovative, nursing-directed practice changes as Edge Runners, and their innovative experiments often produce permanent change (AAN, 2014; Mason et al, 2015). These nurse innovators are working to improve outcomes and the patient experience by reimagining and redesigning healthcare and developing innovative models of care (Mason et al., 2015). Successful initiatives include programs to promote and protect breast-feeding in vulnerable infants; assist the elderly to remain in their homes; improve caregiver skills; provide affordable and culturally sensitive community and family healthcare services; and strengthen parenting skills (AAN, 2014).

Innovations in quality improvement. Initiatives such as the NQS guide quality improvement initiatives and the focus on improved patient outcomes as a measure of payment. These innovations are driving significant changes in the delivery of healthcare. Some of these changes are taking place on a national level. For example, AHRQ has established a Health Care Innovations Exchange to support implementation of evidence-based innovations to improve the quality and safety of healthcare (AHRQ, n.d.). The Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare & Medicaid Services Innovation Center (CMMI) are considering ways to move payment for services for healthcare providers away from a volume based, fee-for-service model and toward payment for quality and value. A recent example is the proposed CMS rule to implement portions of the Medicare Access & CHIP Reauthorization Act of 2015. The proposed rule would establish the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models, or payment models that aim to pay based on quality of care rather than volume of care (Medicare Program, 2016).

Kennedy, Murphy, and Roberts (2013) identified a wide range of activities for nurses at the federal level involving CMS and other agencies, including work on the Measures Application Partnership, the National Priorities Partnership, the Federal Advisory Committees, and the workgroups implementing NQS initiatives. Opportunities to engage in quality improvement initiatives also exist at the local, regional, and state level (Kennedy, Murphy & Roberts, 2013). The IHI has also developed tools to engage front-line staff in activities to innovate and improve quality, such as the Transforming Care at the Bedside initiative (Rutherford, et al., 2008).

There are many examples of nurses creating innovative solutions to address healthcare quality. RN-led protocols have been effective in reducing cardiac surgery readmissions (Sawatzky, Christie, & Singal, 2013). Nurses have implemented innovative measures to address catheter-associated urinary tract infections (CAUTI). For example, Adams, Bucior, Day, and Rimmer (2012) developed a protocol that reduced the number of days a urinary catheter remained in the patient, thereby potentially reducing the risk of CAUTI. The American Nurses Association (ANA), with support from CMS, convened a technical expert panel to develop an evidence-based tool for use by nurses to prevent CAUTI, decrease placement of indwelling urinary catheters, advance timely removal, and employ evidence-based assessments. A nurse-driven protocol for medication reconciliation by Ruggiero, Smith, Copeland, and Boxer (2015) demonstrated that patients discharged from the medical-surgical unit had fewer medication discrepancies, and less likelihood of medication-related error, when two RNs reviewed both patient’s discharge instructions and associated prescribed medications. Nurse-managed protocols have also been identified as an effective method of managing patients with diabetes, hyperlipidemia, and hypertension (Shaw et al., 2014). Moore and Stichler (2015) implemented an initiative where nurses develop quality improvement and evidence-based practice projects to improve patient outcomes.

Not all nursing innovations take place on a large scale or use advanced technology. Not all nursing innovations take place on a large scale or use advanced technology. Stausmire and Ulrich (2015) suggest an innovative approach to identifying and implementing quality improvement projects on a small, unit-wide scale. Another nurse-led innovative change related to hospital-acquired pneumonia is the practice of elevating the head of the bed, which reduced the incidence of ventilator-associated pneumonia (Grap et al., 2005). This is a simple innovation with significant implications for patient outcomes and cost savings.

In addition to improving processes or outcomes, some innovative changes can also drive healthcare savings. One example of such an innovation explored the establishment of a perioperative nurse fellowship program to educate nurses to work in the operating room (OR). Sandhusen, Rusynko, and Wethington (2004) demonstrated a return on investment for such a fellowship with a cost saving of $4,437 monthly, versus utilizing an agency or contract nurse. It is challenging to show a financial benefit to education; this study, which examined a unique program to educate operating room nurses, is an important addition to the literature illustrating quality and cost-effectiveness.

Innovative nurses are influencing the development of health policy... Advancing health policy. Innovative nurses are influencing the development of health policy, which is defined by Longest as, “…authoritative decisions regarding health or the pursuit of health made in the legislative, executive, or judicial branches of government that are intended to direct or influence the actions, behaviors or decisions of others” (2016, p. 11). Byrd, Costello, Shelton, Thomas, and Petrarca (2004) urge RNs to engage in the development of health policy, warning that RNs’ clinical work is impacted by politicians who generally have little to no knowledge concerning how their decisions affect the healthcare system.

Eaton (2012) describes an innovative approach to influencing policy at the state level, where RNs in Virginia educated the public and state legislators to address needed changes to advance nursing education and to increase salaries to nursing faculty in the state. Innovative approaches have also been used to advance nursing education on the importance of health policy. Turale (2015) addresses the importance of having RNs engaged in policymaking, the need to include the process of policy development in the nursing curriculum, and the importance of having nurse leaders mentor new RNs about how to get involved in policy development. An example of innovation in health policy education is described by O'Brien-Larivée (2011), who reported on an innovative approach undertaken in Canada to further the goal of engaging RNs in health policy work through a service-learning experience. Byrd and colleagues (2004) described an innovative series of active learning experiences to educate and motivate nursing students to influence health policy.

Innovation in Health Information Technology
Innovations in health information technology can significantly impact quality of care. Innovations in health information technology can significantly impact quality of care. ANA and other nursing organizations have been strong promoters of new technologies, such as telehealth, electronic health records (EHRs), and patient registries. Grady (2014) addressed the use of telehealth and highlighted the myriad settings where it can be used. Fraher and colleagues (2015) noted that nurses are utilizing HIT to deliver evidenced based care; support communication between providers and with patients; and remotely monitor patients, and also described the utilization of telehealth and data from EHRs as essential for effective care coordination.

Nurses are engaged in a wide range of innovative efforts concerning EHR and health information technology. Walker-Czyz (2016) researched how quality of nursing care was impacted by utilization of an integrated EHR and reported that nurses can utilize integrated EHRs with computerized documentation at the bedside to improve patient care. Weckman & Janzen (2009) described the essential role of nurses in development and implementation of innovative technology (e.g., bar code medication administration (BCMA) system), and highlighted problems of failing to incorporate the nursing perspective. Others have recently reemphasized the essential role of nurses to successfully implement a technology such as BCMA (Vanderboom, et al., 2016).

Specialists in the field of nursing are exploring innovative methods to create a repository of best practices in nursing informatics, and advocating for nursing documentation innovations that are vendor neutral and use a standardized code (Effken, Weaver, Cochran, Androwich, & O’Brian, 2016). A number of ANA policy statements address the role of RNs as innovators and change agents regarding recognized terminologies and other health information technology (HIT) solutions (ANA, 2015b) and standardization and interoperability of HIT (ANA, 2014).

Increasingly, RNs are applying innovative ways to communicate with individuals via cell phones and mobile computer program applications (apps) to assist patients to follow medication protocols; identify reportable signs and symptoms of illnesses or posttreatment complications; learn about appropriate exercises or dietary sources; or find accurate and reliable sources of information about their health needs (Grady, 2014). It is imperative that RNs maximize this opportunity to collaborate with technologists and informaticists to create efficient and effective programs that have a positive impact on patient care and population management (Blahna, 2015).

Big data, described by the National Institutes for Health (NIH) as the, “diverse, complex, disorganized, massive, and multimodal data being generated by researchers, hospitals, and mobile devices around the world” (NIH, n.d., para. 1), offers the potential to revolutionize healthcare. Programs such as the Nursing Knowledge: Big Data Science Initiative (University of Minnesota Center for Nursing Informatics, n.d.) focus on improving healthcare by capturing nursing information in EHRs in a standardized and integrated manner. To use this data, all nurses need to understand how big data works and how it can be used to improve healthcare and the nursing profession (Brennan & Bakken, 2015; Barton, 2016). Nurse educators are called to utilize the power of technology to work toward the vision of a Continuously Learning Health System (Bellack & Thibault, 2016; Josiah Macy Jr. Foundation, 2015). Effective use of data and technology is also essential to quantify and define the value of nursing care and develop payment models that link payment to nursing care (Malloch, 2015; Pruinelli, Delaney, Garcia, Caspers & Westra, 2016; Welton & Harper, 2015).

Simulation Training
 Use of simulation experiences has brought about innovative changes in nursing education... Simulation training can cover a wide range of experiences ranging from role-playing to full mission simulation involving a complex task that engages a team (Galloway, 2009). Use of simulation experiences has brought about innovative changes in nursing education, including using simulation to stimulate critical thinking and create unexpected events (Oliver, Ambrose, & Wynn, 2011); a dedicated education unit as a strategy to decrease the gap between clinical teaching and the classroom setting (Glazer, Erickson, Mylott, Mulready-Shick, & Banister, 2011); and an initiative to staff a university clinical education laboratory with recently graduated nurse interns (Berro & Knoesel, 2016).

Several organizations offer resources to advance innovation in simulation training. The National Council of State Boards of Nursing (NCSBN) has developed guidelines for use of simulation in prelicensure nursing programs (Alexander, et al., 2015). The Simulation Innovation Resource Center, a collaborative project of National League for Nursing fosters nurse education to advance the use of simulation in nursing education, offers a Faculty Development Toolkit and templates (Simulation Innovation Resource Center, n.d.).

Innovations in Delegation Skills
A number of innovations have considered techniques to teach delegation skills to nursing students. For example, creation of case studies set in nursing home practice environments highlights obstacles and impediments to use of best practices for delegating (Day, Turner, Anderson, Mueller, & McConnell, 2014). Nowell (2016) described a simulation experience created to address a number of skills, such as delegation, required of nurses in the current healthcare environment. The NCSBN (2016) recently used an innovative approach to develop guidelines for nursing delegation. A panel of experts from various settings (e.g., practice, education, research) was convened to consider research and current literature on the delegation process. These meetings resulted in the NCSBN (2016) National Guidelines for Nursing Delegation.

Overcoming Barriers to Leading Innovative Change

Important strides have been made in advancing the role of nurses in innovation, but barriers remain. The Institute of Medicine (IOM, 2011) report, The Future of Nursing: Leading Change, Advancing Health, called for expanded opportunities for nurses to lead and diffuse collaborative improvement efforts and to innovate in practice and education. The report recommended funding to advance research on models of care and innovative solutions, including technology, to allow nurses to contribute to improved health and healthcare, and urged healthcare organizations to lead the development of innovative, patient-centered care models. Healthcare organizations are also called to engage nurses to design, develop, purchase, implement, and evaluate health information technology products and other devices. Important strides have been made in advancing the role of nurses in innovation, but barriers remain. This section will consider skills that may help nurses overcome barriers to innovation.

The advance of nursing innovation is also a central focus of the ANA Strategic Goals for 2017-2020. One of the three goals set forth in the Strategic Plan is to “Stimulate and disseminate innovation that increases recognition of the value of nursing and drives improvement in health and health care” (ANA, 2016, p. 2). This goal includes the following objectives:

  • Foster and disseminate nurse-focused innovations and best practices to significantly impact patient and nurse outcomes and generate revenue in priority programmatic areas
  • Leverage data and analytics across the care continuum to drive nurse-led innovations

Characteristics of Successful Nurse Innovators
One approach to foster innovation in nursing is to understand personal characteristics and attributes of nurse innovators... One approach to foster innovation in nursing is to understand personal characteristics and attributes of nurse innovators to determine whether educational levels, certification, training, coaching, or some other variables impact innovative behavior. Dy Bunpin, Chapman, Blegen, and Spetz (2016) noted that there is limited information on the innovative behaviors and characteristics of RNs. Their research expanded this knowledge by identifying characteristics of RNs who scored higher on an innovation scale, including specialty certification, graduate degrees, and experience in management. In addition, they reported that RNs at medium-to-large hospitals and hospitals that had adopted a mid-level of electronic medical records had higher innovation scores. Dy Bunpin et al. (2016) described actions to encourage innovative thinking in RNs, suggested further research about characteristics that foster innovative behavior, exploration about whether patient outcomes are impacted by innovative behavior.

Creating Environments to Foster Innovation
Innovation can be fostered by creating environments conducive to creative thinking and expanding the notion of where and when nursing innovation takes place. Blakeney et al. (2009) described the intersection between environment, creativity, and innovation, and identified environment as an essential element to enable innovation. The innovative process may be more complicated in organizations with bureaucratic decision-making processes, while supportive leadership, a protective or insulated area away from operational pressures, innovation networks, and dedicated time for problem solving can all be conducive to supporting an innovative environment (Blakeney et al., 2009).

Nurse leaders must create environments and opportunities for staff innovation; communicate expectations concerning time commitments and acceptable levels of risk; and allow for failures. Nurse managers and leaders play an important role to create an environment that fosters and encourages innovation. Nurse leaders must create environments and opportunities for staff innovation; communicate expectations concerning time commitments and acceptable levels of risk; and allow for failures (Boston-Fleischhauer, 2016). Creating opportunities for innovation involves acceptance of risk and the unknown, and fostering creativity and intellectual stimulation (Boston-Fleischhauer, 2016). Joseph and Huber also emphasized this point, noting that an effective leader will create an environment that will support new mindsets. There is also potential value in what many managers and business models currently define as “nonproductive” time, or time away when the RN is not providing direct patient care. The availability of such time may be an important tool to foster innovation (Altman & Rosa, 2015).

Health Policy Innovation
Significant time spent with patients combined with functional care activities brings essential understandings to RNs and thus solutions to a wide range of healthcare issues (Patton, Zalon, & Ludwick, 2015). An understanding of health policy allows nurses to participate in the creation and implementation of innovative payment models and healthcare delivery systems.

The American Association of Colleges of Nursing (AACN, 2015) describes three initiatives to advance the involvement of RNs in health policy. These initiatives include:

  • The Health Policy Advisory Council: “created to provide contextual guidance to the association on issues that require insight from nursing academia” (para. 3)
  • The Faculty Policy Think Tank: created to “provide critical insights into the state of policy education in undergraduate and graduate nursing programs” (para. 5)
  • The Invitational Policy Faculty Symposium and Policy Faculty Survey: created “to inform the work of the Faculty Policy Think Tank” (para. 7)

RNs must be knowledgeable and educated about health policy topics and initiatives to ensure that nurses fully participate in health policy innovations. Nurse leaders in academia need to develop and implement curricula and continuing education offerings on health policy topics, and clinical nurse leaders need to mentor new nurses about how to engage in policy work (Turale, 2015).

Developing Leadership Skills
Effective leadership plays an important role to foster innovation in RNs (Dy Bunpin, et al., 2016; Boston-Fleischhauer, 2016). The IHI, with the Robert Wood Johnson Foundation, created a guide to develop nurse managers who can lead improvement and innovation efforts (Lee, Peck, Rutherford, & Shannon, 2008). The strategy developed by IHI requires utilization of a talent management framework; creation of leadership development programs; fostering leaders’ emotional intelligence (EI); and implementing succession planning (Lee et al., 2008).

Researchers have identified characteristics associated with effective leadership. For example, a transformational leadership (TL) style has been shown to contribute to patient safety and creating a safety culture (Merrill, 2015) and to positively impact satisfaction and work environment (Failla & Stichler, 2008). Other research has identified a positive correlation between the concepts of EI and TL style for nurse managers, suggesting that education about TL and EI could impact nursing students and nurse managers in a variety of settings (Spano-Szekely, Quinn Griffin, Clavelle, & Fitzpatrick, 2016; Tyczkowski et al. 2015). Traits attributed to EI in seminal work on the topic included self-awareness, self-regulation, motivation, social awareness, and the concept of relationship management (Goleman, 1995).

Encouraging nurses to develop leadership traits associated with innovation may be an effective method of creating environments where innovation can flourish. A mechanism to allow RNs to improve skills associated with effective leadership is critical. Encouraging nurses to develop leadership traits associated with innovation may be an effective method of creating environments where innovation can flourish. Below we briefly discuss support for several key traits.

Self-awareness. Eckroth-Bucher (2010) reported that on an interpersonal level, self-awareness of strengths and weaknesses can allow an individual to take home the trust of others and increase their credibility; both will increase leadership effectiveness. Some evidence has suggested that the trait of self-awareness can be taught. For example, Vitello-Cicciu, Wetherford, and Gemme (2014) reported that increased self-awareness was one of seven leadership behaviors retained for some months following a leadership development program.

Resilience plays a role in innovation... Resilience. To advance as transformational leaders, nurse leaders should cultivate resilience (Stagman-Tyrer, 2014). Resilience has been demonstrated as a necessary component for the transformational leader to learn, and helps nurse leaders and managers guide others through the difficult process of accepting and implementing innovative changes (Tyczkowski et al, 2015). Resilience plays a role in innovation, can be enhanced and developed, and is an important strategy for nurses (Cline, 2015; Sanders, 2015).

Financial management skills. Nurse leaders have significant budgetary responsibilities but often underdeveloped financial management skills (Douglas, 2010). To operate effectively in a changing healthcare environment, nurse leaders need financial and business acumen (Douglas, 2010; Joseph & Fowler, 2016). They must individually develop an understanding of finances and provide such information to nurses at all levels to drive change and achieve successful outcomes (Talley, Thorgrimson, & Robinson, 2013). Seifert (2012) described the importance of incorporating a business component in nursing curricula and urged nurses to develop knowledge and expertise on business and finance subjects. Lim and Noh (2015) have identified key components for teaching finances to nurses, and the AACN includes specific recommendations regarding finance education in the document, Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008).

The IOM Future of Nursing report (2011) called on the CMMI to develop and evaluate innovative payment models and care delivery systems that use nurses to reduce costs and improve health outcomes. Much of this work is already underway. For example, CMMI has developed a new payment model, the Comprehensive Care for Joint Replacement, to test whether bundled care (i.e., paying for the full episode of care rather than charging separately on a unit or fee-for-service basis) will reduce expenditures while maintaining or improving quality of care (Medicare Program, 2015). Nurses must be educated and prepared to engage in innovative health payment initiatives created by CMMI and other federal agencies. Financial literacy and financial management skills are essential to fully participate in these innovative initiatives.

Critical thinking skills. Critical thinking is a foundational skill that involves ability to apply strong oral and written communication techniques to a variety of environments by utilizing available resources effectively and strategically. It requires analytical skills to assimilate and evaluate data and develop an appropriate response (Bloch & Spataro, 2014). Price (2015) explored the concept of critical thinking as it applies to nursing and articulated a range of critical thinking skills from the relatively simple process of identifying information to evaluating and creatively reframing issues and identifying innovation solutions.

A number of approaches have been recommended to teach critical thinking skills to nurses. Burrell (2014) describes a series of evidence-based methods (e.g., critical reflection on self, environment, and others; concept mapping; and questioning to foster evaluation of complex concepts and issues) to foster creative thinking in nurses. Although case scenarios assist in the development of critical thinking, evidence suggests that real-time scenarios that allow individuals to implement decisions increase critical thinking in individuals such as RNs. Use of clinical simulation, by nurse educators and employers, can be a powerful tool to develop critical thinking and learning (Fero et al., 2010; Kaddoura, 2010).

Recommendations and Conclusion

... nurse leaders need to continue as innovators ... While considering the role of the RN as an innovator, members of the Panel Steering Committee examined barriers to innovation, envisioned the ideal state for an RN functioning as an innovator, and identified three goals and a series of recommendations to advance these goals. Our recommendations include steps to empower all RNs to lead innovation efforts, as well as recommendations for nurse managers and nurse leaders to create environments where innovation can thrive. We also include recommendations targeted to organizations and academia. The information in Table 3 summarizes our goals and recommendations for advancing innovation.

Table 3. Summary: Goals and Recommendations for Leading Innovative Changes

GOALS

RECOMMENDATIONS

Consistent with the ANA Nursing Scope of Standards and Practice, nurses in all roles and settings lead innovative change to protect, promote, optimize, and advocate for the health of individuals, families, groups, communities, and populations (ANA, 2015a). This aligns with the goals of the Triple Aim (IHI, n.d.) and the National Quality Strategy (Mason et al, 2015).

  1. Nurses develop leadership skills (financial, self-awareness, critical thinking) and skills in interprofessional collaboration and strategic reasoning to promote innovation in all aspects of healthcare delivery.
  2. Researchers work to identify key characteristics and attributes of successful nurse innovators.
  3. Nurses achieve positions of influence on national committees and workgroups that design and implement innovative changes to federal initiatives (e.g., National Quality Strategy, payment methodology, quality measures, and other healthcare initiatives).
  4. Employers invest in development of environments that foster nurse innovation.
  5. Nurses share and promote best practices developed through innovative initiatives.

Nurses lead in the development of innovations in health policies by applying nursing knowledge to advocate for patients, consumers, and the nursing profession.

  1. Educators develop and implement curricula and continuing education reflecting health policy concepts and skills.
  2. Nurse leaders mentor new nurses to involve them in health policy development.
  3. Nurses achieve leadership positions throughout the healthcare system (e.g., organizational, local, state, and federal levels) to design and implement innovative changes to health policy.
  4. Nursing organizations monitor health policy regulations to ensure they are supportive of patient care and nursing practice.

Nurses lead, leverage, and advance innovations and technology from inception and development through implementation and evaluation.

  1. Nurses advocate for nursing input to identify the value of nursing services and impact on quality.
  2. Nurses integrate informatics and technology into nursing education (including continuing education).
  3. Nurse educators develop and implement curricula and continuing education reflecting contemporary practice.

For the past 14 years, Americans have rated nursing as the most trusted and most ethical profession (Gallup, 2015). To maintain that standing, nurse leaders need to continue as innovators by directing change, developing policies, and creating innovative technological advancements throughout the nursing profession. Achieving the innovation goals and recommendations described in this article will help to ensure that nurses and the nursing profession have a voice in the future of healthcare.

Acknowledgement

Portions of the research for this article were performed by an American Nurses Association (ANA) Professional Issues Panel entitled “Barriers to RN Scope of Practice.” The panel was composed of volunteers from a variety of nursing backgrounds who contributed through participation on the Panel’s Steering Committee and Advisory Committee. While the articles were generated by authors participating in a Professional Issues Panel convened by ANA, the conclusions and recommendations articulated by any author do not necessarily reflect those of the Association.

Authors

Timothy W. Thomas, BSN, RN
Email: rntthomas@gmail.com

Timothy W. Thomas has worked as a registered nurse for 15 years, and started his career in the U.S. Army at the original Walter Reed Army Medical Center (WRAMC). At WRAMC, he wrote a policy on pressure ulcer prevention and treatment that was later utilized as the framework for a hospital-wide policy. After a short tour in Iraq, he did an inter-service transfer from the U.S. Army to the U.S. Public Health Service (USPHS). In the USPHS, he has been detailed to the Federal Bureau of Prisons (BOP) and has moved up from a clinical nurse, to the Improving Organization Performance/Infectious Disease Coordinator (IOP/IDC), to his current position as Regional Nurse Consultant/Medical Asset Support Team RN for the Southeast Region. In this position, he has led a team of nurses to develop evidenced-based nursing protocols for urgent/emergent situations and for non-emergent, routine care (sick call). He has also co-led the development of the Nursing Services Program Statement for the BOP. In December 2014, he was awarded a full scholarship through the American Nurses Association to complete his masters in Nursing in Leadership and Administration at Capella University, Minneapolis, Minnesota.

Patricia C. Seifert, MSN, RN, CNOR, FAAN
Email: seifertpc@verizon.net

Patricia C. Seifert has more than 25 years of experience as a perioperative nurse. She has been a clinical manager in cardiac surgical services and has developed four cardiac surgical programs. She has also functioned as an RN First Assistant on over 3,000 cardiac surgery procedures. Seifert is a past president of the Association of periOperative Registered Nurses (AORN), past Lead Coordinator of the Nursing Organizations Alliance, a member of Sigma Theta Tau. She is a Fellow in the American Academy of Nursing. Seifert is the author of six books and numerous articles and chapters; she was a member of the writing group for the 2013 American Heart Association Scientific Statement: Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork. She has presented educational programs locally, nationally, and internationally. Seifert was the recipient of the Inova 2015 Ronald S. De Volder Memorial Award for participation in the Cardiac Surgery QI Team Project: “Patient Handoff from CVOR to CVICU and CVICU to CVSDU;” she also received the Inova Health System’s 2014 award for Service Excellence. Seifert has been recognized by her professional organization, AORN, receiving AORN's first President's Award (1991-1992), the 2003 Award of Excellence, AORN's 2007 Jerry G. Peers Distinguished Service Award, and AORN’s 2014 Award for Mentorship.

Jane Clare Joyner, JD, MSN, RN
Email: jane.joyner@ana.org

Jane Clare (JC) Joyner works in the American Nurses Association’s (ANA) Health Policy Department (Nursing Programs). She is a Senior Policy Advisor for health systems and regulatory policy matters. JC is a nurse-attorney with an MSN in Nursing Administration. Prior to joining ANA, she was Deputy Assistant General Counsel for Health Care Operations within the General Counsel’s office at the Department of Veterans Affairs, where she focused on legislation, regulations, policy, and litigation affecting the agency’s integrated healthcare system.

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© 2016 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2016


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