Nurses Too

In my prior post, I made the case that physicians in leadership roles should maintain a clinical practice. Doing so informs their administrative actions, affords them greater credibility with their peers and strengthens a vital link between the bedside and organizational activities. All of those benefits would accrue to nursing leaders who did the same.

In many organizations, as soon as a nurse takes on a defined managerial role (beyond being the “charge” for a shift) he or she leaves the bedside, never to return. They start to dress differently, with the whites or scrubs replaced with business attire and (often) a white coat. In fact, when I was a resident, we referred to the managerial, non-clinical nursing leaders collectively as “plain clothed nurses.” More importantly, I believe they also start to think and act differently.

Some of that difference is important and appropriate. As they advance organizationally, all leaders – not just nurses — must adjust to new responsibilities, acquire and develop new skills and broaden their perspective. Unfortunately, it also often seems as though clinical leaders lose an important attachment to patient care and to their staff when they are no longer “in the trenches” with them. In fact, it seems that much of what nursing leaders are now asked to do by “rounding” on their staff or regularly visiting nursing units is an attempt to replace what they have lost by leaving the bedside – credibility, first-hand knowledge of organizational effectiveness, and connection to purpose.

I think it would be better if they worked a shift now and again instead.

What do you think?



7 thoughts on “Nurses Too

  1. Great point Dr. Nash! To carry this forward, another important perspective for healthcare leaders is to also be patients of their own organizations and experience care from the patient’s vantage point (ideally not as a VIP, but rather one of the masses). The amount of insight and empathy one might glean from being a patient of their own healthcare organization is priceless towards developing patient-centered care.

      1. I agree with this too! I think a lot is learned whether you are a patient at your own institution or at ANY institution. (it is hard to be treated your own institution and not get DIFFERENT treatment from the masses – not always VIP treatment even, just different)

  2. interesting blog, Dr. Nash. As a nurse who does not currently work at the bedside, I have to say YES and NO. In theory this would be a great idea, but in practice it is nearly impossible. I am not in nursing “leadership” as I work in medical research. I can tell you when I moved away from the bedside, I tried to do this on my own. I would sign up for shifts to make extra money when I could. But I was essentially not able to do my job…I could not get meds on my own from our computerized dispensing system, and all the other technology has moved so rapidly that I could not function (from IV controllers, to documentation systems etc). The educational maintenance required to be current on all those things is quite prohibitive (if it were even available!) I come from a SON that practiced the Unification model where educators were required to have clinical roles so I had been brought up to expect that level of involvement but it sure isn’t easy to do!

    1. Thanks for your thoughtful response. Of course there will be impediments that make continued clinical practice difficult, or even impossible; the same is true for many physician leaders. For example, I am not advocating for continuing “low volume” or part-time clinical activities that require highly technical skills. I count myself lucky that I can still practice consultative, outpatient cardiology, even though I would be a hazard if I tried to get back into the cath lab! And, truth be told, I was aiming my remarks more at nurses (and physicians) in organizational leadership, not those who have chosen an alternative, non-patient-facing career path.

  3. Hi, Dr. Nash-

    First of all, I applaud you for hitting a ‘nerve’ of many in nursing practice, particularly those of us in suits and white coats, which due to the nature of our practice, remain white, (albeit the occasional coffee stain.) I myself have been referred to as ‘beeper nurse,’ ‘clipboard nurse’ and in other less friendly terms. Language can define us and shape perception, so I believe we must respect this power by carefully crafting communications.

    Your basic message, I believe, is on target; it is a dilemma when individuals responsible for setting precedence and allocating resource are removed from purpose. The challenge exists for any professionals who assume administrative roles, e.g. teachers who become principals, inventors turning into CEOs, but even more so in healthcare, where change predominates, to remain cognizant of the true issues and needs of those we serve.

    What struck me (almost literally) in your piece is a lack of role validation of the administrator with a clinical background, pursuing a completely different set of competencies. The ability to use resources, connect with people, and to create, follow and lead a group toward a vision are all distinct skills, ones that are learned, practiced, and refined over time. For example, combining the need for effective, compassionate, goal-oriented patient care with financial viability requires talent not taught in medical or nursing school. Many years ago, none of us would have believed this; however we have recently seen hospitals in our communities disappear.

    Nursing leaders need to balance credibility and effectiveness, while trading clinical expertise for a new, yet equally important, skill set. One cannot, and need not, excel in everything simultaneously. A renowned oncologist could not consult on chemotherapy treatment on Monday and perform cardiac surgery on Wednesday; similarly, nursing leadership must be viewed as a defined specialty. That said, the afore-mentioned balance does require interface with the clinical area, which, incidentally, is achieved through administrative rounding. Purposeful rounding is not a horse and pony show, but rather an opportunity for executives to feel the pulse of their assigned areas. Other strategies include involving clinical front-line workers in high level decisions, listening to them and valuing their input, just as we partner with patients to determine their best course.

    While a clinical director in a busy emergency department, I poignantly remember a day when, as I ‘clicked’ my heels through my unit, donned in street garb and white coat, a Patient Care Associate (PCA) called out to me, requesting that I bring him a urine specimen cup, as he couldn’t leave his patient. Relieved this was a task of low-complexity (that I could still manage!), I went beyond by actually retrieving and transferring the sample to said collection device, and discarded the remainder. When I presented the completed product to the PCA, the grateful yet astonished look on his face was embarrassing. Word spread through the unit of my heroic action; it was as though I had inserted a chest tube! Like episodes serve to maintain credibility, and provide a sound basis for decisions. I don’t intend to imply that all nurses should stick their fingers in pee for a few minutes per week to maintain relevancy, but you get the picture.

    Conversely, administrators cannot serve as everyday problem solvers or pinch hitters by forfeiting their own responsibilities, and must comfortably acknowledge front line staff as expert.
    The belief that nursing leaders should spend some time operating as staff nurses is disquieting on several fronts.
    1. Minimizes the role of the direct care nurse as easily replaceable. Safe performance requires on-going education, and continuous practice.
    2. Could compromise outcomes as the time and expense of activities required to maintain competence are not practical, creating potential for inappropriate staffing.

    So, I arrive at the following conclusions, which summarize where I agree with your query, yet have concern with some messaging:

    • Leadership in Nursing, or any profession, should be regarded and respected as a distinct science, art, and service, requiring particular knowledge, competency, training, evaluation, and yes, attire.

    • The road to clinical competency is rigorous and cannot be compromised; only those who maintain expected levels of education and practice should provide care.

    • Aptitude in health care management should include professional background in the respective area. It is dually important to have mechanisms to connect with and involve the front line in decisions that drive outcomes. This can be achieved through various means, and certainly warrants further reflection.

    Thank you for providing some food for thought; on behalf of my profession, I aim to assure that nursing as a science is perceived accurately in all roles, so we can continue to hold ourselves to the highest standards.

    Jaclyn Schindler, FNP-BC, RN-BC

    1. Thank you for your thoughtful contribution to the conversation. I totally agree with your point that administrative effectiveness requires a distinct skill set from clinical expertise. I did not intend to (nor do I believe I did) imply that clinical expertise is all you need to be an effective organizational leader. Plenty of great clinicians fall flat when “promoted” to leadership positions, so we are in agreement that leadership “should be regarded and respected” separate and apart from clinical expertise. What I did say is that ongoing clinical work “informs … [leaders’] administrative actions, affords them greater credibility with their peers and strengthens a vital link between the bedside and organizational activities,” which I stand by. In fact, I think your anecdote about the ED is a good illustration of exactly that — enhanced credibility that came from “walking the walk.”
      Your point about the need to maintain clinical competency is, of course, also well taken. I agree that anyone in a clinical role has a professional and ethical responsibility to maintain competency, and for some, because of the technical or rapidly changing nature of their field, this may be impossible. I would not want to have heart surgery performed by someone who was “keeping a hand” in it while shouldering full time leadership duties, and I wouldn’t want my ICU nurse to be unfamiliar with the medications, treatment protocols or equipment required to provide excellent care. That said, I bet there are plenty of experienced nurses who retain great judgement and clinical reflexes who could function effectively on a part-time basis as they develop the new skills required to be effective organizational leaders.

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