The Journey of 10,000 Miles Begins With 1 Step Lucy Leclerc, PhD, RN-BC
T
he journey to providing world-class health care can be gauged by various
metrics: some are more tangible and concrete, such as patient satisfaction scores, whereas others aren’t necessarily readily seen or felt. Nursing identity, role clarification, and owning nursing practice are all less measurable, yet immeasurably vital elements of a journey to excellence. In our world of immediate gratification with instant everything from messaging to downloads to “show me the results…now,” the world of professional nursing practice challenges the perceptive norms of our health care world. Things that take
time, such as cultural change related to how nurses see themselves as professionals, elbow to elbow with their interdisciplinary colleagues as well as their peers, doesn’t happen overnight. Developing and nurturing professionalism in nursing takes time, authentic presence of leaders, engagement of colleagues, and somehow creating a feeling of value in the contribution of each nurse from the bedside to the boardroom. So how does that happen? Not an easy answer, but the professional practice team at WellStar Cobb is on a mission to make it happen. This is the story of a team’s vision to define themselves and become owners of their practice.
“W
hat is professional practice and what exactly do you do?” Repeat a hundred times. When I first started at WellStar Cobb Hospital last year as the director of professional practice, I was unprepared for the number of times I was met with the preceding question. Not just non-nurses such as physicians, C-suite execs, or pharmacists, but nurses themselves! I arrived at a time when the department had just shifted its moniker from professional development to the more apropos term, professional practice. Changing that 1
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word threw us all off, but if we look at the reason why, we should all be excited about it. Development is a more narrow term that focuses on an actionable process in which nurses engender growth, clinically and professionally. Development, as a departmental identifier, implies the team’s purpose is to provide development opportunities, which isn’t necessarily a bad thing, but puts the onus on the team rather than the ownership on each registered nurse as a member of a profession. Practice is inclusive of much more than development.
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Practice embodies the idea that our nursing world is complex and requires critical thinking, self-governance, crucial conversations, teaching, learning, growing, mentoring, nurturing, transparency, competence, caring, authentic presence, intuition based in experience, and continually seeking to improve. Oh, and what about research, academic mobility, advanced practice, participation in professional organizations, and serving our community? Registered nurses have really important roles! Finally, think about the basic meaning of the word practice and consider its parallel use in medicine. We’re all familiar with hearing the concept of physician practice. Physicians practice medicine. What do nurses do? Do we commonly say that we practice nursing? Or do we say, “I’m a nurse” and then list a bunch of tasks to validate our existence? Moving from development to practice is a way for nurses to recognize that we indeed practice nursing as a member of a profession. The monumental task before us, though, isn’t necessarily convincing others that we’re professionals, it’s convincing ourselves. Defining and owning our practice is the first step. When I first hit the beautiful and diverse world that is Cobb Hospital, I realized, in the mantra of a well-schooled student of psychology, that we needed to start with ourselves. Our team had to be able to answer the FAQ of the year, which is who are you and what exactly do you do? The Nursing Professional Practice Team at WellStar Cobb Hospital is a dynamic team of 3 clinical nurse specialists (CNSs), 8 clinical nurse leaders (CNLs), and 12 clinical nurse educators (CNEs). The team is led by a PhD-prepared RN with American Association of Colleges of Nursing certification in Nursing Professional Development (me). An interesting aspect of our team is that the 23 team members are deployed in every clinical department, from the emergency department to the operating room, to labor and delivery to neonatal intensive care unit, and to every acute care unit inbetween. In contrast to the situation with most nursing teams, there’s no central location for our team where we see each other every day. In fact, when I arrived, I soon realized that some nurses on our team had not ever met each other. During my initial assessment, I made 2 foundational observations: first, our team didn’t feel like a team because of the geographical challenges; and second, we were having serious identity crises within each role and as a team. Despite the continual enthusiasm of others to try to get to know what a professional practice team is and does, we had a hard time with our elevator speech. We really couldn’t say what our vision and mission were. We even had a challenging time explaining to people how the 3 roles truly were different and how they worked as a collaborative team. We each knew our role as a CNS or CNL or educator, but there were challenges in translating that to our partners and customers. We were in that awkward adolescent phase where our voices cracked and we were morphing from the more easily understood “development team” to the less tangible “practice team.” The first big step was to gather for team-building retreats. As I said earlier, our team needed a venue to develop collegial relationships between CNLs, CNSs, and educators. We had to www.nurseleader.com
meet, greet, and get to know each other. We had to learn how to play off of each other’s strengths. It was a first step. After the first few retreats, I gathered a subgroup with representative CNLs, CNSs, and educators to start an appreciative inquiry (AI) process that would put us on the road to identity crisis recovery. For those less familiar with AI, it’s a model of research or change theory designed to engage stakeholders in selfdetermined transformation.1,2 AI differs from traditional change theories because rather than focusing on a problem or deficiency as a foundation for change, AI focuses on current strengths and positive aspects of what’s working well in an organization or entity. The beauty of AI is best described by one of AI’s prolific organizational theorists, Bushe, who states: “Appreciative Inquiry advocates collective inquiry into the best of what is, in order to imagine what could be, followed by collective design of a desired future state that is compelling, and thus, does not require the use of incentives, coercion, or persuasion for planned change to occur.”3 AI is based on an assumption that the questions we ask will lead us in a particular direction and that the evolution of an entity will occur in parallel to the questions we most persistently and passionately pursue. AI is not just a positive way to approach a problem, it’s actually transformational because it’s a collective effort and hinges on the creative generation of new ideas to address old problems. In its simplest form, AI allows those at the epicenter of the problem to discover, dream, design, and deliver transformational and positive change.1–3
DEFINE AND DISCOVER As I stated earlier, we were experiencing a crisis in identity, collectively and by role. We were now on a mission to define ourselves. In one of our early AI sessions, the subgroup of CNLs, CNSs, and educators developed a first draft of defining each of the roles.4–8 They then presented it at our collective team meeting, and what you see in Figure 1 is the result of input from every team member. It may seem simple, but this exercise was eye-opening because the team discovered overlap in certain domains such as education and competencies. The team gained perspective on how to best complement each other rather than duplicating efforts. Discussion was lively, and in the spirit of AI, we maintained a focus on what worked well in each role.
DREAM You’ve got to love a change process that allows you to dream. When it came time to consider a future state, the team initially reverted to a natural inclination to state what currently existed rather than what could be. There was a sense of surprise that they could consider something different, that they could create a vision and mission that was of their own accord, developed with their own unique knowledge of their professional roles. This contrasted with their experience and history of being defined by other entities such as parallel professions (physicians) and a top-down nursing leadership mandate. It took some convincing, but they quickly embraced the ability to dream of a future state over their former way of practice based in tribal knowledge.
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Figure 1. CNS, CNL, and Educator Roles
Professional practice defined the roles of the CNS, CNL, and CNE.4–8
The team worked over a period of months to develop a vision and mission congruent with WellStar’s nursing mission and vision. The team also took care to address each of the 5 concepts in WellStar’s professional practice model. After many spirited discussions, reminiscent of academic-level discourse, the team dissected every word for fit and congruence. Mission: incorporate evidence-based practice (EBP) into the professional growth and development of the WellStar Cobb nursing team to provide safe, high-quality care to achieve optimal outcomes. Vision: foster a healthy work environment that promotes: • Professional development—serve as national leadership champions through collaboration and growth • EBP & research—create and integrate innovative practices • Exemplary practice & outcomes—promote and recognize nursing excellence • Teamwork & collaboration—participate in multidisciplinary committees and mentor shared governance • Resources & support—achieve optimal outcomes.
DESIGN The next step was organic in response to defining our roles and creating a vision and mission. The team worked long and hard to create a visual representation of how each role in our professional practice team works uniquely and in concert with each other. The model is thoughtful in many aspects, one of which is the fact that our team lies within
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the WellStar professional practice model (the outer circular border) (Figure 2). The collective nature of the design is evident in every detail. For example, the most vibrant colors were dedicated to each of our roles and then to our customers, which are our nurses and our patients and families. Neutral colors were used for our partners to indicate collaboration and consultation. Having been in nursing for nearly 3 decades, I can’t recall feeling more in awe of a group of professional registered nurses. The Cobb professional practice team was not only defining, but also owning, their practice. They were thinking differently and seeing themselves differently. It may sound corny, but they stood taller and started speaking more confidently about who they are and what they do. We finally had answers to all those people asking questions.
DELIVER One of the final steps in our journey of 10,000 miles was to disseminate and garner feedback from our partners, our customers, and our colleagues. We shared our vision, mission, and care delivery model with our partners, customers, and leaders. We started locally with our customers and partners at Cobb Hospital. This was valuable in setting expectations for how our team could serve both our customers and our partners. Additionally, our partners were gaining a much more lucid comprehension of how the 3 roles complemented each other, as well as how our team is designed to work with
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Figure 2. WellStar Professional Practice Department Model
The professional practice department model visually represents how the team interacts with each other, with our partners, and with our customers. The WellStar nursing professional practice model on the outer edge of the circle provides the mechanism for pulling it all together under 1 cohesive concept.
them, not always for them. Remember, our team members are deployed in clinical areas throughout the hospital and work closely with nurse managers, so this education was crucial in strengthening partnerships. From there, we shared our model with the professional practice teams at the other legacy WellStar facilities. Each professional practice team took the model and customized it based on the roles within their facilities. For example, not all of our legacy facilities have the CNS role. On a regional level, we delivered our model as a poster presentation at the Kennesaw State University EBP Toolkit Conference in September 2016. This afforded the opportunity to share our best practices and change process with our regional colleagues. On a national level, the team presented their work at the CNL Summit in February 2017 to an audience of CNL peers from across the nation. Finally, the team was honored to represent WellStar nursing and WellStar Cobb Hospital at Sigma Theta Tau International’s 27th International Nursing Research Congress, Leading Global Research: Advancing Practice, Advocacy, and Policy. The team that traveled the 10,000 miles to Cape Town, South Africa, in July went knowing they represented our entire professional practice team at Cobb. The team includwww.nurseleader.com
ed Kendra Mathis, CNL, MSN, RN; Tammy Wilson, CNE, MSN, RN; Muun Queen Malone, CNS, MSN, RN; Renecha Abrams, CNS, MSN, RN; and Lucy Leclerc, PhD, RN-BC. The team provided an engaging podium presentation to a packed concurrent session that included a mix of academic and clinical nurses. There were many positive comments noting the relevance of our journey in defining and owning our nursing practice. Also, the question and answer time was filled with unique inquiries about each role, which were eloquently addressed by each of our team members. The experience was life-changing for our 4 team members who were able to present to an international nursing audience. Interestingly, this was the first podium presentation for Kendra, Tammy, Renecha, and Muun. They showed the world what “world class” at WellStar means.
CONCLUSION As we all live and breathe, so does nursing practice. The journey to excellence is organic, alive, and will be ever-changing. What a great challenge for all of us as nurses. The professional practice department model at WellStar will change as well. We live with the practical expectation, within a complex and diverse health care system, that our roles will evolve, shift, and
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Figure 3. The WellStar Cobb Professional Practice Team Members
The WellStar Cobb professional practice team members presenting at Sigma Theta Tau International’s 27th International Nursing Research Congress, Leading Global Research: Advancing Practice, Advocacy, and Policy. Pictured from left to right: Kendra Mathis, CNL, MSN, RN, Tammy Wilson, CNE, MSN, RN, Lucy Leclerc, PhD, RN-BC, Renecha Abrams, CNS, MSN, RN, and Muun Queen Malone, CNS, MSN, RN.
change to benefit our patients and the environment in which our nurses practice. I challenge you to take this story and this model as a template to create your itinerary on the journey to excellence. For us, this is just the first chapter with many plot developments to be determined. The journey of 10,000 miles is really just the beginning. NL References 1. Cooperrider DL, Sorensen PF Jr., Yaeger TF, Whitney D. Appreciative Inquiry: An Emerging Direction for Organization Development. Champaign, IL: Stipes Publishing; 2001. 2. Cooperrider DL, Whitney D, Stavros JM. Appreciative Inquiry Handbook. Bedford Heights, OH: Lakeshore Publishers; 2003. 3. Bushe GR. Appreciative inquiry: theory and critique. In: Boje D, Burnes B, Hassard J, eds. The Routledge Companion to Organizational Change. Oxford, UK: Routledge; 2012:87 103. 4. American Association of Colleges of Nursing. White Paper on the Education and Role of the Clinical Nurse Leader. Revised 2007. http://www.aacn.nche.edu/publications/white-papers/ClinicalNurseLeader.pdf. Accessed August 9, 2016. 5. Bender M. Conceptualizing clinical nurse leader practice: an interpretive synthesis. J Nurs Manag. 2016;24:E23-31. 6. Bender M. The current evidence base for the clinical nurse leader: a narrative review of the literature. J Prof Nurs. 2014;30:110-123. 7. Bender M, Connelly CD, Glaser D, Brown C. Clinical nurse leader impact on microsystem care quality. Nurs Res. 2012;61:326-332. 8. Nelson R. Clinical nurse leader: an update on the controversial nursing role. Am J Nurs. 2010;110:22-23.
Note: The Professional Practice Team at WellStar Cobb Hospital acknowledges the support of our partners and administrative team in making our journey successful. Specifically, we want to thank Kay Kennedy, Chief Nursing Officer, and Jill Case-Wirth, Chief Nurse Executive. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 1541-4612/2017/ $ See front matter Copyright 2017 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2017.03.015
Lucy Leclerc, PhD, RN-BC, is director, Professional Practice, at WellStar Cobb Hospital in Austell, Georgia. She can be reached at
[email protected].
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