Frontline Leaders Research Articles

Exploring the Prevalence of Adverse Childhood Experiences in Soldiers Seeking Behavioral Health Care During a Combat Deployment.

This exploratory study examines the prevalence of adverse childhood experiences (ACEs) in soldiers who sought behavioral health support during a combat deployment. We conducted a secondary analysis of data extracted from two studies on the basis of retrospective reviews of behavioral health records of soldiers deployed to Iraq or Afghanistan. Of 162 clinical samples, 135 (83%) reported at least one type of childhood adversity. ACE scores ranged from 0 to 9 with a mean of 3 (standard deviation = 2.4) and mode of 0. A total of 65 (40%) experienced four or more ACEs. Parental divorce or separation was the most frequently reported childhood experience and was associated with witnessing domestic violence, having a member of the household abuse substances, and being physically and psychologically abused as a child. A sizeable proportion lived with a household member who had been in prison. Soldiers with an extensive history of ACEs may benefit from additional mentoring from frontline leaders and prevention measures instituted by unit behavioral health personnel.

Earning Your “Gait Belt” in Lean: “Stopping the Line” Through a Staffing Response Team

As the health care industry struggles to adopt Lean practices from our colleagues in manufacturing, translating those concepts to the frontline staff and leaders can be challenging. In an effort to increase value to our patients by eliminating waste, increasing standardization, and engaging the expert frontline staff in problem solving, many of us struggle with translating the core concepts of Lean, let alone earning a coveted green or black belt. Health care systems such as Virginia Mason, Theta Care, and Stanford may have successfully implemented many of the practices that will earn a green or black belt of distinction, but for many of us, just like a gait belt, we are looking for something to provide security and support to stabilize our efforts. We continue to require reinforcement that we are following the core principles of Lean and are heading in the right direction.

The Roles of System and Organizational Leadership in System-Wide Evidence-Based Intervention Sustainment: A Mixed-Method Study.

If evidence-based interventions (EBIs) are not sustained, investments are wasted and public health impact is limited. Leadership has been suggested as a key determinant of implementation and sustainment; however, little empirical work has examined this factor. This mixed-methods study framed using the Exploration, Preparation, Implementation, Sustainment (EPIS)conceptual framework examines leadership in both the outer service system context and inner organizational context in eleven system-wide implementations of the same EBI across two U.S. states and 87 counties. Quantitative data at the outer context (i.e., system) and inner context (i.e., team) levels demonstrated that leadership predicted future sustainment and differentiated between sites with full, partial, or no sustainment. In the outer context positive sustainment leadership was characterized as establishing a project's mission and vision, early and continued planning for sustainment, realistic project plans, and having alternative strategies for project survival. Inner context frontline transformational leadership predicted sustainment while passive-avoidant leadership predicted non-sustainment. Qualitative results found that sustainment was associated with outer context leadership characterized by engagement in ongoing supportive EBI championing, marketing to stakeholders; persevering in these activities; taking action to institutionalize the EBI with funding, contracting, and system improvement plans; and fostering ongoing collaboration between stakeholders at state and county, and community stakeholder levels. For frontline leadership the most important activities included championing the EBI and providing practical support for service providers. There was both convergence and expansion that identified unique contributions of the quantitative and qualitative methods. Greater attention to leadership in both the outer system and inner organizational contexts is warranted to enhance EBI implementation and sustainment.

Partnerships to Improve Oral Hygiene Practices: Two Complementary Approaches.

The omission of oral care is linked to increased nurse workload and may contribute to serious patient infection and growing healthcare costs. Therefore, ineffective oral care comprises a significant patient safety issue across healthcare settings internationally. As studies have demonstrated a positive relationship between Nurs Leadersh (Tor Ont) and improved patient outcomes, it is imperative that leaders seek effective approaches to facilitate contextual exploration of barriers and facilitators for resolution of oral care delivery problems. One approach to improved processes of oral care is the creative engagement of front-line clinicians in the problems they confront in everyday practice. By drawing upon the role and process of facilitation, we outline two projects, located in Australia and Canada, that engaged front-line nurses, health leaders, and researchers as partners to identify a path to improved oral care delivery. In this paper, we summarize key learnings for nursing leaders about strategies to facilitate delivery of fundamental oral care. We found that facilitation, contextual knowledge and academic-clinician partnerships were essential to the detection and evaluation of oral care delivery problems and the identification of priorities for practice improvement. As collaboration is imperative for sustainable innovation, we summarize strategies of effective leadership for improving oral care delivery.

Factors of Successful Women Leadership in Saudi Arabia

<p>Saudi woman encounters many shapes of sexual segregation that stand as an obstacle against her option to occupy a frontline leadership position. There are misconceptions in our society that women are not even suitable for leadership. This paper aims to highlight the factors promoting success in leading organizations in general and the success of women in particular with highlighting the status of Saudi women in these factors. The main hypothesis is “the more the woman has factors of leadership, the more success she may achieve in leading organizations”. A model including the factors promoting successful Saudi Women Leaders is proposed and discussed to ensure accuracy of the above mentioned hypothesis. The findings expect bright future for Saudi women in light of keenness of King Abdullah to support woman to play her role in the society and preserve the rights to demonstrate her success in leadership.<strong></strong></p>

Navigating Through Chaos: Charge Nurses and Patient Safety.

The aim of this study was to explore actions and the processes charge nurses (CNs) implement to keep patients safe and generate an emerging theory to inform CN job descriptions, orientation, and training to promote patient safety in practice. Healthcare workers must provide a safe environment for patients. CNs are the frontline leaders on most hospital units and can function as gatekeepers for safe patient care. This grounded theory study utilized purposive sampling of CNs on medical-surgical units in a 400-bed metropolitan hospital. Data collection consisted of 11 interviews and 6 observations. The emerging theory was navigating through chaos: CNs balancing multiple roles, maintaining a watchful eye, and working with and leading the healthcare team to keep patients safe. CNs have knowledge of patients, staff, and complex healthcare environments, putting them in opportune positions to influence patient safety.

Engaging Frontline Leaders and Staff in Real-Time Improvement

The relationship of staff satisfaction and engagement to organizational success, along with the integral influence of frontline managers on this dimension, is well established in health care and other industries. To specifically address staff engagement, Virginia Mason Medical Center, an integrated, single-hospital health system, developed an approach that involved leaders, through the daily use of standard work for leaders, as well as staff, through a Lean-inspired staff idea system. Kaizen Promotion Office (KPO) staff members established three guiding principles: (1) Staff engagement begins with leader engagement; (2) Integrate daily improve- ment (kaizen) as a habitual way of life not as an add-on; and (3) Create an environment in which staff feel psycho- logically safe and valued. Two design elements--Standard Work for Leaders (SWL) and Everyday Lean Ideas (ELIs) were implemented. For the emergency department (ED), an early adopter of the staff engagement work, the challenge was to apply the guiding principles to improve staff engagement while improving quality and patient and staff satisfaction, even as patient volumes were increasing. Daily huddles for the KPO staff members and weekly leader rounds are used to elicit staff ideas and foster ELIs in real time. Overall progress to date has been tracked in terms of staff satisfaction surveys, voluntary staff turnover, adoption of SWL, and testing and implementation of staff ideas. For example, voluntary turnover of ED staff decreased from 14.6% in 2011 to 7.5% in 2012, and 2.0% in 2013. Organizationwide, at least 800 staff ideas are in motion at any given time, with finished ones posted in an idea supermarket website. A leadership and staff engagement approach that focuses on SWL and on capturing staff ideas for daily problem solving and improvement can contribute to organization success and improve the quality of health care delivery.

Abstract TP402: Stroke Nurse Coordinators: Role in Transient Ischemic Attack (TIA) Care in the National Veterans Health Administration

Background: With the purpose of identifying gaps as well as best practices in guideline-concordant TIA/minor stroke care in the Veterans Health Administration (VHA) system, we sought to elucidate the perceived challenges and facilitators of TIA care across clinical specialties and across settings of care. Methods: We conducted a prospective, formative evaluation in 14 VHA hospitals across the US. We conducted 70 semi-structured interviews with front-line clinicians, leadership and quality managers. Interviews were audiorecorded, transcribed, and double coded in Nvivo 10 software using an emergent codebook. We analyzed the reported challenges and facilitators of TIA guideline care. Results: Six of the fourteen sites reported the existence of a Stroke Nurse Coordinator to track the quality of stroke care and to minimize the gaps in services across inpatient and outpatient settings. Of the six, only one site had a defined algorithm for TIA care services specifically for and separate from their stroke protocols. A lack of care coordination for TIA patients across services and across the inpatient and outpatient settings were major reported challenges. Sites without a stroke coordinator often reported a lack of staff to reduce this service gap. Some provided outpatient follow-up as well as risk factor management at the inpatient bedside for all admitted TIA patients and this appeared to facilitate TIA care. Educating facility staff for stroke care was a common responsibility, but few stated they provided TIA-specific staff education. Stroke/TIA quality data collection was often performed by the Stroke Nurse Coordinator; however the data feedback process varied widely across facilities from none to a stroke team, and by schedule from weekly or, quarterly to occasionally. It is unclear how the Stroke Nurse Coordinator interacted with the neurology service from these data, but the six sites with a Stroke Nurse Coordinator had much lower rates of consulting the Neurology service. Conclusions: Extending the role of the local Stroke Coordinator to include specifying a TIA protocol, assisting care coordination for patients with TIA, tracking and feeding quality data back to local providers may improve the quality of TIA care. SDP # 12-178.

Igniting Change Through an Empowered Frontline: A Unique Improvement Approach Centered on Staff Engagement, Empowerment, and Professional Development

Although many improvement models utilize a leadership or “top down” approach to change, North Shore University Hospital opted to ignite change by implementing a transformation model that would focus on engagement, empowerment and professional development all with the frontline staff as pivotal change agents. The approach centered around development of an “army “of frontline leaders who would work collaboratively and drive change across the organization. This innovative approach resulted in a hospital-wide culture change evidenced by remarkable improvements in quality, patient experience, professionalism, engagement, and overall care delivery. Although many improvement models utilize a leadership or “top down” approach to change, North Shore University Hospital opted to ignite change by implementing a transformation model that would focus on engagement, empowerment and professional development all with the frontline staff as pivotal change agents. The approach centered around development of an “army “of frontline leaders who would work collaboratively and drive change across the organization. This innovative approach resulted in a hospital-wide culture change evidenced by remarkable improvements in quality, patient experience, professionalism, engagement, and overall care delivery.

The transformation of governance: public administration for the twenty-first century

The traditional theory of public administration is based on entrenched notions of hierarchy and authority. However, as the structure of public work has grown less hierarchical, managers have adopted a wide variety of non-authoritarian strategies. This growing gap between theoretical ideas and actual practice poses enormous challenges for front-line leaders struggling to deal with ever-larger expectations and ever-tighter budgets-and for American government in determining how best to hold public administrators accountable for their performance. The Transformation of Governance offers a new framework for reconciling effective administration with the requirements of democratic government. Instead of thinking in terms of organizational structure and management, Donald F. Kettl suggests, administrators and theorists need to focus on governance, or the links between government and its broader environment-political, social, and administrative-through which social action occurs. In this updated edition, a new epilogue shows Kettl urging political leaders to step back from the political barricades of hyperpartisanship to consider government's contemporary dilemma: Is there any practical way forward for public administrators to manage government effectively? Reinforcing the ten principles of bridge building which he developed in the original book, Kettl adds an eleventh, which lays out five transformative strategies: redefining public law to promote public accountability; re-conceptualizing government agencies as instruments of leverage; launching government leaders as boundary spanners; using information technology for building authority and trust; and incorporating performance management into processes that drive collaboration. With a new preface from Michael Nelson, editor of the Interpreting American Politics series, this award-winning book will be sought out by public policymakers eager to read a leading scholar's newest insights into the field.

Cultural Complementarity: Reshaping professional and organizational logics in developing frontline medical leadership

With the rise of clinical management, new skills of medical doctors stand out, including leadership skills. Medical doctors organize medical work and improve patient care. The training of frontline leadership skills, however, is weakly developed in residency programmes. Medical professional cultures tend to resist organizational techniques and values. This paper analyses cultural interventions in health-care organizations, aimed at overcoming ‘clashes’ between professional and organizational logics in frontline domains. These interventions do not work against, but ‘use’ professional traditions, styles and customs as cultural resources. We use one particular project to illustrate this, a project in which internal medicine residents are invited to join quality improvement sessions, during which they identify critical (organizational) experiences with care provision and realize change. We show how residents feel enabled to establish results and cooperate with other professionals. We also show how this project links organizational responsibilities and medical professionalism – how complementarity (instead of conflict) is established. This is done in practical ways, which commit instead of alienate medical professionals.

Observing practice leadership in intellectual and developmental disability services.

Improving staff performance is an issue in services for people with intellectual disability. Practice leadership, where the front line leader of a staff team focuses on service user outcomes in everything they do and provides coaching, modeling, supervision and organisation to the team, has been identified as important in improving staff performance. To date this finding is based only on self-report measures. This paper describes and tests an observational measure of practice leadership based on an interview with the front-line manager, a review of paperwork and observations in 58 disability services in Australia. The measure showed good internal consistency and acceptable inter-rater reliability. Practice leadership was associated with staff practice and outcomes for service users. The observed measure of practice leadership appears to be a useful tool for assessing whether leadership within a service promotes enabling and empowering support by staff. It was found to discriminate higher and lower performing services in terms of active support. The measure had good reliability and validity although some further testing is required to give a complete picture of the possible uses and reliability of the measure. The measure is potentially useful in contexts of both research and service development. The confirmation of previous findings from self-report measures that practice leadership is related to the quality of staff practice and outcomes for service users has implications for policy and practice in terms of the training of managers and structures for organisational management.

Enhancing Clinical Support and Collaboration through Creation of a Standardized Critical Event Debrief Process

<h2>Poster Presentation</h2><h3>Purpose for the Program</h3> Obstetric‐related critical events are self‐defined, often unexpected, traumatic events with the potential to involve multiple staff members that result in strong emotional responses for which usual coping mechanisms may be ineffective. Health care professionals are trained to clinically respond to patient‐related events; however, they may not have the resources to adequately respond to emotions triggered by these events. Health care providers in these situations may have feelings of worry or grief after the event. If these feelings are not addressed, they may lead to increased stress, hindrance of the ability to provide good care, and burnout. Debriefing is a group meeting arranged for the purpose of recounting and fact gathering after a critical event has occurred. The purpose is to help review processes and improve clinical practice, provide staff with emotional and psychologic support, and foster teamwork. <h3>Proposed Change</h3> To conduct a standardized debrief with the individuals involved in a critical event to help staff members discuss the event and identify who may need additional clinical or emotional support. <h3>Implementation, Outcomes, and Evaluation</h3> This hospital created a standardized debrief tool for utilization in newly established critical event debriefs. Critical events were described as self‐identified and included near misses, significant medication errors, and adverse events. As frontline leaders, unit‐charge nurses were the targeted group for initial education on the new, hospital‐wide, critical event debriefing process. They were educated on the purpose and importance of conducting a timely and confidential debrief after a critical event. The newly developed paper tool was presented to this group along with a discussion of the phases of debriefing that were used to structure the tool and common factors that may enhance or hinder an individual's response to the event. A counselor from the Employee Assistance Program was brought in to teach nurses how to conduct an emotional debriefing session. Feedback since implementation of the debriefing process has provided clinicians and the organization with valuable information that has been used to improve patient care and processes, communication between departments, and teamwork. <h3>Implications for Nursing Practice</h3> Empowering frontline leaders with the tools and resources to conduct debriefings after critical events is crucial to help review and improve clinical practice. In addition, the debriefing session provides a safe place to examine feelings, thoughts, and responses to the event to allow nurses to prepare for potential future events.

Journey to Reducing Catheter Associated Urinary Tract Infections

BackgroundCatheter Associated Urinary Tract Infection (CAUTI) is the most common type of Healthcare associated Infection (HAI). There has been an increase in CAUTI awareness due to public reporting and changes in the Centers for Medicare and Medicaid reimbursement (CMS). Numerous strategies have been employed to reduce CAUTI, but those proven most effective have been the placement of catheters only for appropriate indications, removing the catheter as soon as possible, and employment of a nurse driven protocol.MethodsAn infection Preventionist, nurse leader, and physician leader formed a multidisciplinary team and set a goal to reduce the incidence of inpatient CAUTI in a 684 bed teaching hospital. The multidisciplinary team met monthly with the primary focus being implementation of a nurse driven urinary catheter removal protocol along with indications for placement of a urinary catheter and indications to culture urine. The education was offered to staff via multiple learning platforms.ResultsConclusionsCMS and public reporting changes brought CAUTI infection rates to the attention of front line leaders. A multidisciplinary effort in a CAUTI reduction intervention reduced infection rates and catheter utilization drastically. The effects of the intervention have been sustained over time with the use of the nurse driven urinary catheter removal protocol. BackgroundCatheter Associated Urinary Tract Infection (CAUTI) is the most common type of Healthcare associated Infection (HAI). There has been an increase in CAUTI awareness due to public reporting and changes in the Centers for Medicare and Medicaid reimbursement (CMS). Numerous strategies have been employed to reduce CAUTI, but those proven most effective have been the placement of catheters only for appropriate indications, removing the catheter as soon as possible, and employment of a nurse driven protocol. Catheter Associated Urinary Tract Infection (CAUTI) is the most common type of Healthcare associated Infection (HAI). There has been an increase in CAUTI awareness due to public reporting and changes in the Centers for Medicare and Medicaid reimbursement (CMS). Numerous strategies have been employed to reduce CAUTI, but those proven most effective have been the placement of catheters only for appropriate indications, removing the catheter as soon as possible, and employment of a nurse driven protocol. MethodsAn infection Preventionist, nurse leader, and physician leader formed a multidisciplinary team and set a goal to reduce the incidence of inpatient CAUTI in a 684 bed teaching hospital. The multidisciplinary team met monthly with the primary focus being implementation of a nurse driven urinary catheter removal protocol along with indications for placement of a urinary catheter and indications to culture urine. The education was offered to staff via multiple learning platforms. An infection Preventionist, nurse leader, and physician leader formed a multidisciplinary team and set a goal to reduce the incidence of inpatient CAUTI in a 684 bed teaching hospital. The multidisciplinary team met monthly with the primary focus being implementation of a nurse driven urinary catheter removal protocol along with indications for placement of a urinary catheter and indications to culture urine. The education was offered to staff via multiple learning platforms. Results ConclusionsCMS and public reporting changes brought CAUTI infection rates to the attention of front line leaders. A multidisciplinary effort in a CAUTI reduction intervention reduced infection rates and catheter utilization drastically. The effects of the intervention have been sustained over time with the use of the nurse driven urinary catheter removal protocol. CMS and public reporting changes brought CAUTI infection rates to the attention of front line leaders. A multidisciplinary effort in a CAUTI reduction intervention reduced infection rates and catheter utilization drastically. The effects of the intervention have been sustained over time with the use of the nurse driven urinary catheter removal protocol.

Strategies to Engage Frontline Teams and Leaders in Sustainable Change

A rapidly changing healthcare environment requires organizations to engage staff and physicians in new ways. External forces and internal priorities with decreasing resources create the need for innovative strategies to improve clinical outcomes, engage staff and physicians and meet the needs of patients and families. Barriers to safe reporting and participation in improvement work must be overcome before staff will feel secure enough to be involved in quality and patient safety initiatives. Safety forums, Robust Process Improvement®, microsystem assessment and Kaizen methodologies were utilized to assess current state, prioritize initiatives, implement changes and engage frontline staff and physicians. A variety of strategies were identified that engage frontline staff and align executive teams with frontline teams and microsystem level leaders.

Assessment of current antimicrobial stewardship policies and resources: a focus group project

Abstract Introduction Antimicrobial stewardship (AS) within acute care facilities is a requirement for Accreditation Canada's Required Organisational Practices. In order to obtain a baseline evaluation of current AS processes, a focus group approach was used to qualitatively assess frontline pharmacy staff and leadership perspectives on AS resources. Methods A semi-structured interview process was applied to focus groups comprised of Pharmacy Services employees throughout Alberta Health Services in Alberta, Canada. A thematic analysis of transcripts was done independently by two investigators, and consensus was reached on identified themes and topics. Codes were recorded for prevalence and total number of mentions. A combination of conventional and deductive approaches was used to identify themes. Results A total of 200 (10%) pharmacy services staff members participated in the focus groups. Eight main themes were identified: antimicrobial resources, influences on antimicrobial utilisation, barriers to antimicrobial stewardship, establishing AS teams, education needs, improving communications, antimicrobial utilisation concerns, and enablers for improvement. Two hundred and six topics were identified to support the themes, with 1924 data points. Prominent topics included ubiquitous awareness of a provincial antimicrobial stewardship reference, prescriber preferences influencing antimicrobial utilisation, and desire to improve interprofessional teamwork, communication and educational opportunities. Conclusions A broad description of the culture of antimicrobial use showed that the themes are interrelated. To successfully change practice, one must take into account the complexity of the relationship between these perceptions.

Use of a professional practice model to illuminate the importance of relationships.

At the Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute (OSUCCC-James), implementation of relationship-based care (RBC) and primary nursing (PN) along with enculturation of the James Nursing professional practice model (PPM), have improved patient and nurse satisfaction. This article describes the importance of relationships with self, colleagues, patients and families, and the community. Best practices and outcomes are shared to inspire others who seek to transform professional practice environments and organizational cultures by focusing on patients and families and engaging frontline leaders in the change process.

The Business Women’s Association of Uzbekistan: A qualitative study of the emergence and potential influence of women’s leadership in Central Asia

This phenomenological study used the first five steps of a modified van Kaam method by Moustakas in conjunction with semi-structured interviews to explore the lived experiences of a sample of front line leaders of the Business Women’s Association of Uzbekistan (Tadbikor Ayol) that operates in an environment hostile to women in general and to businesswomen specifically. The association, founded in 1991 continues to develop and mentor the women entrepreneurs of Uzbekistan. Discovering the factors that influence the viability and sustainability of the BWA as it continues to operate in a challenging cultural and political environment and the applicability of the factors to Central Asia was the focus of this study. The results of the research identified five themes: 1) leadership style; 2) seminars and skill building activities; 3) peer and family relationships; 4) financial support; and 5) government relations.

Why Hospital Improvement Efforts Fail: A View From the Front Line

In the 21st century, healthcare executives are facing changes of unprecedented magnitude in virtually every area, affecting their ability to compete. That hindrance brings with it a greater need for rapid and effective organizational change and improvement. Yet changes in the U.S. healthcare delivery system have historically been criticized as slow and less than effective in responding to the changes necessary for rapid performance improvement. To that end, the purpose of this applied research study was to help healthcare executives better understand the barriers to effective organizational change and improvement from the perspective of frontline leaders. Focus groups were conducted with 167 frontline leaders from four community hospitals to explore why hospital change efforts fail. Participants representing 11 different functional areas, including all facets of hospital operations, were asked to identify the primary causes of failure of a recent change initiative at their hospital. A content analysis of the focus group data identified 10 primary barriers to successful hospital change, some of which are ineffective implementation planning and overly aggressive timelines, failure to create project buy-in and ownership, ineffective leadership and lack of trust in upper management, unrealistic improvement plans, and communication breakdowns. Leadership lessons and recommendations based on the research findings are provided.

Leadership at the front line: Impact of practice leadership management style on staff experience in services for people with intellectual disability and challenging behaviour

Background The aim of this research was to explore the impact of a particular management style called practice leadership upon the experience of staff working in services for people with intellectual disability and challenging behaviour. Such staff have been shown to experience high stress and lack of job satisfaction. Support by the immediate manager may be an important ameliorating factor. However, style of manager support requires further exploration.Method A single point-in-time survey of staff in adult residential services within the South East of England collected data on practice leadership, stress, and positive work experiences.Results Practice leadership was positively associated with lower stress, greater positive work experiences for staff, and more strongly associated with “developmental” than “supportive” leadership. Effect sizes were small to medium.Conclusions Staff experience of working in challenging environments may be improved by style of front-line leadership. However, further conceptualisation and research of staff experience and practice leadership is required.