This issue focuses on the theme ‘Achieving Excellence in Nursing Management’. Whilst the most important activity in health care today happens at the point of care and is provided by nursing staff; nurse managers, directors, leaders and educators have a pivotal role and opportunity to create and maintain a culture of excellence. Nursing excellence thrives in patient care areas when staff is supported by a healthy work environment in which to practice; given the tools of professional development; and encouraged, mentored and recognized. This edition of the Journal of Nursing Management is a ‘must read’ from cover to cover for all nurse managers. The authors of the articles, commentary and conference report cover many topics that provide new knowledge, strategies and best practices for management and, ultimately, promote achievement of excellence in nursing management for the 21st century. Excellence, by definition, means a state of (high) quality, superiority, eminently good, superior or first class. In nursing management literature, ‘excellence’ is not a new topic, but rather has been a focus of interest since the early 1990s. Pursuit of ‘excellence’ became a common theme during the 20th century and authors have written about the topic from different perspectives in health care (Pimpel et al. 2003, Lipsy 2005), practice (Driever et al. 2007), continuing education (Green et al. 2005), nursing science (e.g. Flaming 2002, Kirkevold 2002), health care management research (Issel 2010) and also medicine (Bove 2008, Miller 2009). It is possible to claim that today the ‘journey to excellence’ with its processes, structures and outcomes has been well described (e.g. The Magnet Model Components and Sources of Evidence, 2008). However, at the same time, the challenges of achieving and sustaining excellence have also become clearer and more evident (Sharkey et al. 2009). In a very recent article, Stichler (2010) has pertinently described excellence as being as elusive as a butterfly: it can land for a moment to share its beauty, but it can fly away with the smallest breeze. So, the true challenge for leadership and management today is not just to achieve excellence, but also to nurture and sustain it so that excellence becomes a prevailing and eternal part of professional nursing practice. A healthy work environment is crucial for nursing practice, optimal patient outcomes and ultimately clinical excellence. Literature consistently supports the pivotal role of leadership in creating, shaping and sustaining healthy work environments (Whiley 2001, Marcus & Liberto 2003). Furthermore, it is suggested in the literature that a healthy and effective work environment includes at least the following four characteristics: (1) respectful and fair treatment of employees, (2) strong sense of trust between management and employees, (3) organizational culture that supports communication and collaboration and (4) feeling of emotional and physical safety (see e.g. Heath et al. 2004). The first set of six (6) articles focuses on studying and discussing the topic of the healthy work environment. Kramer and colleagues report noteworthy findings regarding the Healthy Work Environment from an extensive recent study from 34 Magnet Hospitals in the United States. The study shows interesting differences: 54% of the 540 clinical units were determined by nurses to be very healthy work environments, 28% as healthy work environments and 18% of the work environments needed improvements. This research demonstrates that the ‘bar’ is set high for very healthy and healthy work environments, but also that there is always room for improvement in any Magnet hospital. As the authors point out in the discussion, nurse managers can use surveys to conduct a gap analysis, and when necessary, focus attention where changes are needed to improve work environments in all clinical units. Where the work environments are healthy, the surveys can help to validate and sustain excellence. Mays and colleagues introduce an instrument that has been developed to evaluate the direct care providers’ work environment in the hospital settings. The items of this instrument are based on the American Association of Critical Care Nurses (AACN) standards for a healthy work environment. The approach and perspective of this instrument is oriented to asking nurses to grade themselves and their co-workers on how well they incorporate each of the six AACN standards into their practice. In her commentary paper, Ritter presents perspectives on the current literature regarding healthy work environment which focus especially on the issue of retention. The author argues that the literature provides clear evidence of the link between work environment and retention, and also to excellence programs such as Magnet and the Beacon Award. The key message to nursing management and administration is that there is an urgent need to evaluate the health of the work environment and support improvements if they are to retain nurses during the upcoming nursing shortage. Gormley’s article presents findings from an empirical study which examines the differences in perceptions of work environment and quality of care between nurse managers and staff nurses and the relationship between nurses’ perceptions of the work environment and intention to leave. The study shows that there are significant differences between nurses’ and nurse managers’ perceptions of work environment. The important point here is that if one of the key characteristics of healthy work environment, communication and collaboration, remains without attention the nurse managers and leaders may employ initiatives to improve the work environment that are not necessarily important to the staff nurses. Han and Jekel give an interesting new perspective to the healthy work environment, especially to respectful and fair treatment and turnover intentions. This empirical study investigated the mediating role of job satisfaction between leader-member exchange and turnover intentions. The findings reinforce the role of managers and the importance of cultivating the quality of relationships between their staff/nurses since it is possible to claim that this relationship significantly enhances nurses’ job satisfaction and in turn, lowers their turnover intentions. Turnover rates are commonly used as one of the outcomes measures that demonstrate excellence (see e.g. Stichler 2010). Hillman and Foster focus on describing the development and evolution of a residency program for new graduate nurses. They also present the measurement of outcomes in relation to resident retention and associated cost savings. An important observation in this article is that the adoption and implementation of the residency program represents a change in an organization’s culture, especially its hiring and education practices. It is thus also possible to assume that a residency program is a powerful strategy to promote a healthy work environment in an organization. It is possible to claim that there are at least five evidence-based management practices that are today consistently necessary elements of the health care work environment: (1) balancing the tension between production and efficiency, (2) creating and sustaining trust, (3) actively managing process of change, (4) involving staff in decision making pertaining to work design and flow and (5) using knowledge management to establish a learning organization (see e.g. Institute of Medicine, 2004). The key to success, in fact, rests within the ability of leaders and managers to translate the evidence into practice at the bedside. The following five (5) articles discuss the challenges of nursing work from different perspectives and together suggest that nursing management needs to be diligent in taking a broader approach to provide support in different ways to nurses to preserve their commitment to clinical excellence. Chen and colleagues report new findings from an empirical study which shows the physiological and behavioral response patterns to work stress today among hospital nurses. The findings demonstrate that nurses experience physiological strain in the course of their work and underscore the importance of balancing the physically hard work with adequate breaks, proper work accommodations, and health promotion interventions. Koivu and colleagues describe the characteristics of nurses who decide to attend clinical supervision. There is evidence that clinical supervision provides peer support and stress relief, promotes professional accountability and skill and knowledge development. Yet, in spite of its potential for positive impact, some nurses choose not to participate. The study shows that leadership, and arguably this is related to trust, is one of the most influential factors impacting attendance, but also that nurse managers have a key role making clinical supervision available and accessible and thus enabling better balance between work, efficiency and nurses’ professional efficacy. Change and conflicts are common in nursing. Brinkert presents a case study and describes conflict coaching as a practical and effective means of developing the conflict communication competencies of nurse managers and their supervisees. This study was done in a Magnet designated health system with a teaching college. The article is an interesting example from a change management perspective aimed at excellence. Spivak and colleagues present three case studies which exemplify decision making by nurse leaders related to retention of expert nurses in the workforce. The article shows the importance of skilled nursing leaders to be actively involved with their staff and to understand each expert nurse’s motivation, values and challenges, but also how to encourage and help individual nurses to develop or transition into roles that lead to success for both them and the organization. Martin’s article reports findings from an empirical study which focuses on nurses’ ability and willingness to work during pandemic flu. The study shows that nurse managers can take several actions that convey the employer’s concern for the safety and well-being of the staff and demonstrates that the employer understands the importance of the duty to care for staff. Evidence-based practice, utilization/management of knowledge and quality are increasing expectations in today’s health care environment. This is not always simple or easy, but requires leadership from nurse managers. The next set of four (4) articles describes utilization of existing knowledge, research that identified a ‘best practice’ risk assessment tool, and the development of critical thinking skills in the new nurse. Since nursing is not a static profession but one which is constantly changing and reaching for higher levels of clinical excellence, it is imperative that nursing managers fully support both the acquisition and utilization of nursing professional knowledge. Solomons and Spross present an integrative review of the literature focused on evidence-based practice barriers and facilitators from a continuous quality improvement perspective. The article provides a new perspective on the topic and interesting information showing that, in fact, the barriers and facilitators occur at both individual and institutional levels. The conclusions provide important insight to solutions directed to the different dimensions where barriers occur, but also to multi-dimensional approaches which are essential to overcoming these barriers. Gifford and colleagues describe the development of leadership to facilitate evidence-based guideline utilization. The importance of leadership in the use of guidelines has been recognized, but interventions to develop leaders for this purpose are not well identified in the literature. The article describes the planning and evaluation of leadership interventions to facilitate the use of foot ulcer guidelines in home health care. Excellence is often measured in terms of patient outcomes, with nurse sensitive indicators, such as, for example, fall rates, pressure ulcers, and noscomial infection rates. Chapman and colleagues report a study comparing simultaneously four fall risk assessment tools. The article is interesting from the perspective that the researchers invited staff nurses to participate in the identification of the best possible instrument. Earlier studies have shown (e.g. Moffa et al. 2010) that engaging clinical nurses in the work of quality and performance improvement is essential to achieving excellence in clinical care. Marchigiano and colleagues describe the findings from an innovative initiative aimed at developing critical thinking skills for clinical assignments with nursing students. This article is interesting since its focus is on promoting excellence in our future nurses. Nurse managers are, of course, in a key organizational position for supporting and promoting the education of new nurses and developing the students’ critical thinking skills for managing patient care. An international reader may wonder, what does organizational level excellence mean? Literature in nursing and allied health sciences (e.g. Stichler 2010; see also Denton 2006, Bove 2008, Miller 2009) is showing increasing interest on organizational excellence using different metrics such as high profile awards and recognitions. Among these, Magnet designation is gaining momentum internationally. The impetus behind the Magnet movement is its sole focus on nursing and high level of excellence of nursing care services. In this issue we present an interesting article on Magnet from an international perspective. Spicer and colleagues report the findings of their study on Chinese directors of nursing and chief operating officers’ competencies using a framework based on the original forces of Magnetism. Overall, the findings show the transferability of the original forces of Magnetism to nursing management with an international perspective. The final paper in this issue is a conference report written by the Magnet commissioner representing nurse managers. Selig provides an overview of the annual Magnet conference with an explanation of its history, the conference offerings, a presentation of the different learning tracks and conference highlights. While many of the issues facing the United States and health care reform are unique, the Magnet conference presents many unifying themes that resonate with nurses from around the globe. The readers of this editorial may have already realized that the journey to excellence is challenging, but also highly rewarding. This journey requires transformational and courageous nurse managers, leaders and educators who are willing to be transparent, empowering, innovative and risk taking, who insist on evidence-based practices and continually measure and improve outcomes to ensure the highest possible quality of service. This is the most important work we have ahead of us in the decade to come. Finally, the editors would like to thank all the authors for sharing their perspectives and work to illuminate the important theme of this issue.
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Open Access
Dec 26, 2023
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