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Staying abreast of leadership

Nursing PRN Spring 2017


How do today’s nurse leaders stay at the top of their game—and inspire their teams to do the same?

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“Michele, we need you in Theatre Six.”

Such calls are all in a day’s work for Michele Derbyshire, long-time nurse manager at Mazankowski Heart Institute’s Unit 3A9 in Edmonton. Despite being out of scope, she routinely dresses in scrubs and caps her hair so she can dash into one of the unit’s six operating rooms at a moment’s notice to guide the team through rough patches.

“Having that frontline interface every day and knowing the issues, I’m able to smell the smoke and stop the fires from starting,” she says. “Some say if you have a leadership background you can walk into any area, but I find having an understanding of the clinical side very much a benefit. People respect that you know their role.”

Inspired by a predecessor who involved the entire unit in striving for excellence, Derbyshire has nurtured what she calls “a pretty well-tuned engine”—an expert team of nurses and allied health professionals who work together seamlessly to provide excellent patient care. “I have staff who are—in my mind—at the pinnacle of their clinical expertise and working to the full scope of their practice,” she says. “We are not nitpicky about who does what and who can talk to whom.” In fact, colleagues in other units express amazement at the frank and open conversations that occur with the physician team.

This egalitarian approach extends to leadership, including the task of keeping abreast of the latest developments in a unit that sees rapid-fire change. As Derbyshire frequently reminds staff, she is not the sole source of essential knowledge. “That role is divvied up among specific people who become my go-to experts,” she says as we chat in the quiet alcove that welcomes visitors to the unit (which she’s proud to say she helped design with ample input from staff). “I lead by allowing key people to take ownership of projects and portions of the day-to-day running of the department.”

Shared leadership. It’s essential. Especially in today’s Alberta, where a collaborative model of acute care is putting a greater onus than ever on RNs to employ leadership skills every day.

From solo to team

Colleen Ubbing is one of the unit managers giving shape to the collaborative model of care recently rolled out by Alberta Health Services—a model that sees RNs, LPNs and health care aides team up in “hubs” to look after particular patients.

As Edmonton’s Grey Nuns Hospital prepared to open its doors in 1988, Ubbing was among the first nurses hired. She then bounced from facility to facility during the cutbacks of the 1990s, soaking up diverse experiences that she now realizes helped equip her for leadership. But the Grey Nuns Hospital remained her facility of choice. Returning there in the late ’90s, she soon became one of the hospital’s first unit managers. Fourteen years later, she continues to lead Unit 51 (medicine), the very floor where her career began.

Along the way, Ubbing has seen nurse leaders such as herself overwhelmed by ballooning responsibilities that pull them away from the people they serve. “We take care of 50 staff, while others above us take care of 8 to 10,” she says. “We were told we could leave the desk and come into the office to do administration, but that’s like running two cars going in different directions at 200 miles an hour.”

Similar dilemmas face nurses on the front line as they struggle with increased caseloads, lengthy assessments and escalating recordkeeping, she says. “Everything is so technical, and people are so acutely ill. What I mourn most is that we don’t deliver the personal care we used to.”

“ The LPN scope of practice has grown through the years, and we’re trying to grow the RN scope as well.” 
Colleen Ubbing
 

Ubbing hopes the shift to collaborative care, with LPNs and health care aides both taking on tasks that were previously outside their scope, will help everyone share the load of patient care while empowering RNs to hone their leadership skills. To that end, she has trained nearly all of the 24 RNs on her team to serve as charge nurses, equipping them to supervise the unit desk, speak with doctors and families, process orders—and think critically about issues that inevitably arise. She’s also happy to see increasing interest in an in-scope leadership program in which RNs receive additional education and mentoring and apply their expertise on the unit. “The LPN scope of practice has grown through the years, and we’re trying to grow the RN scope as well,” she says.

The shift from primary care to collaborative teams has the laudable goals of enhancing patient care and slowing the escalation of healthcare costs. Visiting a friend in care at the University of Alberta Hospital, I see first-hand the positive impact of the shift. When more than one person is required for such tasks as turning and bathing, there are readymade partners for the task—partners who consider this patient theirs to care for. But I also learn of the RNs’ angst at carrying a larger caseload and having fewer RNs on the floor.

It’s no surprise that the change to team-based care is causing angst, says Kari Krell, assistant professor with MacEwan University’s Centre for Professional Nursing Education. Not only is there “role confusion,” as those involved sort out who does what, but mismatches are likely to appear between old procedures and new expectations, she says. “The call is to support and mentor nurse leaders so they can embrace these changes and be proactive rather than reactionary. A great leader inspires others and equips them to handle change and disruption while making sure feedback and suggestions from the front line filter back up to management.”

It’s also essential to ensure that wisdom is not lost in the shift, Krell adds. “Senior nurses have this great base of knowledge. We need to capture that and transfer it to new nurses.”

Capturing wisdom

At Foothills Medical Centre in Calgary, Unit Manager Michelle Bonnier’s team includes nurses with as much experience as her mom, who worked her entire career as an RN. Although those senior nurses report to her, she learns from them every day, as do others on the ward.

Bonnier stepped into leadership remarkably early in her career. After working at Foothills as an undergraduate nurse, she was hired there in 2011 as a new RN. Before long, she volunteered to chair a unit council that brought diverse disciplines together to identify quality improvements. Her unit manager went on maternity leave soon after, and Bonnier was entrusted with leading the unit. Having enjoyed the critical thinking required to facilitate “the best care possible within that broader setting,” she applied when the unit manager position came open permanently and won the post. Just a year and a half after earning her degree, she began managing PCU 102, a general surgery/surgical oncology unit.

“It was challenging going from colleague to manager, especially as a newer nurse,” Bonnier recalls. “I was not prepared for a formal leadership position.” In particular, she recalls her first few difficult conversations as incredibly challenging. “You plough through, reflect on your practice, identify gaps, grow and learn. And you surround yourself with excellent mentors.”

From older nurses on her team, Bonnier has learned the value of being fully present at the bedside. “These nurses lived through the transition from hands-on care to the broader scope we see now, and they beautifully meld leadership with holistic care. That’s so good for new nurses to see and, for me, a reminder of why we are all here,” she says. “There’s a lot of talk about nurses as leaders, and that’s very important, but the movement toward leadership cannot mean a movement away from patient care. Being there to ambulate or change a patient is part of servant leadership.”

Unit managers and their superiors are equally responsible for inspiring a culture of care, says Covenant Health’s Ubbing. “I believe in getting out there and working with my staff, role modeling it. I say, ‘I do not have the clinical skills you have, but I have other skills.’ When we have an emergency, they know I can assess patients and determine what needs to be done.”

Learning as leaders

Even for nurses who study and practice leadership at every step of their journey, each new post demands renewed dedication to learning.

Like many of the RNs she mentors now, Ubbing served as a charge nurse before becoming unit manager at Grey Nuns. But from her very first day at the helm, with her program manager beyond hailing distance due to a broken ankle, she realized how much she didn’t know: union contracts, scheduling, confidentiality, system politics, personality differences, cultural dynamics, diverse management styles, care concerns. Mastering it all took years of experience, supported by a broad range of mentors.

The hardest lesson, she says, was this: “You can’t be friends and be their boss.” Even now, she lies awake at night, mulling over difficult conversations that impact lives and careers. “Nobody likes being the bad guy,” she says, comparing the sad task of uncovering inept care to peeling away layers of an onion to reveal increasing rot. Every nurse shares responsibility to sound the alert when a colleague is putting patients at risk, she notes. “But as unit manager, you are paid to make those tough decisions—to call them on that.”

In her early days as unit manager at Foothills, Bonnier teamed up with another recently minted leader to form a new-manager support group, a place to talk frankly about the anxieties inherent in what she terms a “jack of all trades” position. “Middle management is a very good term for the job—helping frontline staff while trying to meet the needs of the organization,” she says. The group proved a valuable font of ideas for dealing with that tug and pull.

“ I enjoyed my RN training, but as an undergraduate you don’t really have a framework for building a theoretical foundation. Living through the experience makes those theories real and applicable.” 
Michelle Bonnier
 

In addition, Bonnier took advantage of courses and mentorship within and beyond Alberta Health Services and completed a Master of Nursing through Athabasca University. She highly recommends being a leader while studying leadership. “I enjoyed my RN training, but as an undergraduate you don’t really have a framework for building a theoretical foundation,” she says. “Living through the experience makes those theories real and applicable.”

Derbyshire’s learning journey at the Mazankowski illustrates the diversity of opportunities available to nurse leaders. She has taken advantage of Alberta Health Services’ array of leadership courses, including a recent day on disclosing difficult news that netted some “aha” ideas to share with colleagues. She keeps tabs on the latest research, including the studies and trials made possible by the institute’s affiliation with the University of Alberta. She draws on the expertise of a senior in-house quality consultant as well as the department’s quality council. And she relies on an ever-growing network of mentors.

“When I started, I was putting out fires most of the time,” Derbyshire says, recalling her first tough months as unit manager, 18 years ago. “But who wants to put out fires every day?”

Wide-angle influence

Advocacy is a core aspect of nursing leadership, whether for a single patient or for the profession. As the Canadian Nurses Association puts it, “Nurses have the obligation to their clients to demand practice environments that have the organizational and human support allocations necessary for safe, competent and ethical nursing.” With roles continuing to evolve and dollars tight, that advocacy is more essential than ever.

For Ubbing, Derbyshire and Bonnier, advocacy includes sitting on advisory councils at MacEwan University. Derbyshire advises MacEwan’s perioperative program, which prepares RNs and LPNs for work in settings such as hers. “Being part of the council allows us to get a foot in the door as to what they learn and the way they learn, both clinical and theoretical,” she says.

Derbyshire is also opening doors to operating room experience for LPNs in training. “It’s been a real struggle for us to find that niche of LPNs who are going to succeed in our setting,” she says. Using methods learned through quality assurance networks, she and another nursing manager analyzed why they were having trouble finding appropriately trained LPNs , identified nursing programs as potential partners and urged NorQuest College to add an operating room option for LPN students doing practicums. The option is piloting this year, and although Derbyshire is proud to say she has no vacancies now, the time will come when she’ll be drawing from the resulting pool of applicants. As often happens, by advocating for improvements in the profession, Derbyshire expanded her own leadership skills and brought benefits back to the home team.

Bonnier sits on Calgary Zone committees that address medical management and safety—positions she would not have imagined holding a decade ago. (“I was nervous to speak to patients, I was that shy,” she says.) But at this early point in her leadership career, her own unit claims almost all her time and energy. “I would like to do more, but the frontline management role is very dense, very busy,” she says. “We spend a lot of time coaching. By investing in staff and empowering them, I am working to make a difference to the patients and families we serve.”

Inspiring tomorrow’s leaders

Indeed, Bonnier, Derbyshire and Ubbing all put a high priority on developing the next generation of leaders—nurses who embrace change without losing the essential qualities of holistic care. They’re always on alert for nurses who show particular aptitude for leadership.

“We tell new staff, ‘Give yourself six months to a year to get comfortable. But after that time, are you growing in responsibility—whether helping colleagues, or seeing growth in your practice, or considering the bigger picture?’” Bonnier says. “Those are skills we look for.”

Her advice to aspiring nurse leaders: “Look at the patient as a whole person. Take a step back and ask, ‘What does this patient need?’ When you do that, it’s easier to do the same when you have a broader leadership scope.”

In Ubbing’s unit at the Grey Nuns, emerging leaders play key roles in such areas as advancing clinical care, enhancing safety, mentoring peers and coordinating the social events that help bond a unit into a team. “Any project we have, I choose different people, depending on their strengths,” she says.

Ubbing’s advice: Embrace the challenge of leadership. “Taking leadership roles and responsibility keeps you interested and engaged in what’s happening.”

“ It’s surprising what a network you can develop—and how important those relationships can be.” 
Michele Derbyshire
 

Growing a leader, like collaborative care, takes a team, Derbyshire observes. “When you have that spark in you that wants you to do it, rely on your employer to provide resources, look for leaders and managers who mentor you and seek out supportive colleagues.” Her own path to becoming the unit manager who can smell the smoke before the fire begins provides an instructive example. “I’m not an island,” she says, recalling mentors who’ve walked with her through tough times, including the death of two staff members. “I bank off other people for support and guidance through the good and tough times.”

Her advice: “Don’t go driving on empty; gas is cheap. It’s surprising what a network you can develop—and how important those relationships can be.”

Like most things in life, leadership grows when it’s shared.


The Centre for Professional Nursing Education provides continuing education for nurses and health-care professionals.