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By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Peter Drucker, considered the father of modern management theory, frequently talked about the problem leaders have in making decisions to stop doing things. The default in healthcare is to keep adding more. Addition addiction is a real problem today that frontline nurse leaders frequently discuss. Professionals are often asked to pick up more tasks and responsibilities. These incremental changes add up over time. When new staff assume roles, they do not have the luxury of assuming role responsibilities gradually. The outcome is that new staff feel overwhelmed with what they are expected to learn and do.

When preparing my keynote for last year’s AONL conference, I conducted five focus groups with frontline nurse leaders nationwide. They repeatedly talked about the scope creep in their roles and those of the staff. The default always seems to be that nurses are there with the patients, so add it to their role. Jeff Mills, a CNO who worked with me on conducting focus groups with frontline leaders, noted that a great question in response is – well, if nursing were not the solution to this problem, how would we get this done?

So, how do we stop this addiction? I think the answer is to require that when something is added, something else is subtracted. But to do that, you need to discuss with staff what could be eliminated. The following are some good discussion points to have with nurses today:

1. What parts of our care could we eliminate or reduce and lose little value to the patient?
2. What aspects of our nursing role could a staff member with less expertise do?
3. What are your role’s five most consuming parts, and how can we streamline or eliminate them?
4. What redundancies in our current processes could we eliminate to save staff time?
5. Are the emerging technologies that we are using consuming or saving time? Can we start demanding that all new technologies we purchase integrate seamlessly and put data into the EMR?
6. Are we leveraging our electronic health records to their fullest potential, or are we slaves to documentation?
7. What can we do to streamline communication in our system?
8. Are our processes too complicated? How could they be streamlined without compromising safety?

Today, we know that the burden of documentation on clinicians is one of the most serious problems in healthcare. Those present during the introduction of electronic medical records probably remember all the promises about how these records would save time. Instead, they have become a prime example of addition addiction.

Several nurse leaders recently discussed their unhappiness with EPIC’s (the largest EHR provider in the US) failure to take responsibility for reducing the documentation burden on staff in conversations with me. The solution they report is always purchasing another product—why should that be, and why don’t they take a page from the Apple playbook? We need to have these conversations in healthcare today as resources become tighter and clinician workforce shortages grow.

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By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

When I conduct focus groups with young nurses for organizations, I repeatedly hear a theme: They don’t see any loops being closed on problems and challenges. It is one reason why many pull back from shared governance efforts. It is critical today that nurse leaders have a bias for action.

When a problem or challenge is within a leader’s circle of influence, nurses today expect you to act decisively and close the loop quickly. When you think about today’s fast-paced world, your nurses can order something from Amazon and see it delivered within hours in some areas. Yet, repairing equipment on units essential for care can take weeks. Decision-making in healthcare organizations is notoriously slow, and even simple policy or practice changes can take a long time to wind through multiple committees for approval. Too often, the loop on a decision is never closed. Baby boomers and Generation X tolerated attending meetings where you might see the same agenda item for discussion month after month, but younger staff will not. As one young nurse recently told me in a focus group – why should I waste my time when nothing happens with our input? He makes a good point.

Not all decisions leaders make have the same consequences, so they may not need the same level of contemplation. In Jeff Bezos’s book Invent and Wander, he points out that sometimes people think about all their decisions in the same way when they are not. He divides decisions into two categories. The first category is one-way-door decisions. These are critical decisions that are highly consequential and usually irreversible. To change one’s mind after the fact can lead to disaster. Bezos thinks these decisions should be thoroughly debated and analyzed from multiple angles.

There is a second type of decision, which Bezos calls a two-way-door decision. These decisions are reversible. If the decision proves to be wrong – you change. Two-way-door decisions require less debate because they are reversible. Most daily decisions that we make in nursing would fall into this category. Nurse leaders today should work to have a bias for action. If the decision can be easily undone, move quickly and make the decision. If the decision cannot easily be undone, take your time. In either case, the key action is to keep staff informed and close decision loops even if the decision is no. Remember that no decision is a decision, and indecisive leaders frustrate staff.

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By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

A seasoned nurse leader recently asked me if it was just her perception or if things were shifting so quickly with the nursing workforce that many of her well-honed strategies no longer seemed to work. She began noticing a cultural shift in her team two years ago, but now it seemed more profound. I asked her about her team’s demographics, which few leaders seem to track.

As she looked at her staff profiles, she noted that the average age of her staff was now about 26, whereas in the past, it was closer to 36. She had onboarded 45 new graduates into her ED last year alone- a staggering number. Before COVID, she rarely, if ever, hired a new nurse with less than one year of experience.

This leader now sees the power of the magic third in her team’s culture. More than half of her staff are now Generation Z nurses with a different career outlook than previous generations. In his book Revenge of the Tipping Point, Malcolm Gladwell elaborates on the concept of the “magic third.” When a demographic, such as Generation Z, constitutes one-third or more of the current staff composition, their values, attitudes, and beliefs significantly influence and change a unit’s culture.

The magic third helps explain why some nurse leaders have significant staff challenges with issues like time and attendance, declining baseline mental health, lack of professional identity, communication skills, teamwork, professional accountability, and long-term retention, while others may not. It also explains why units with younger staff are more likely to embrace new technology and change. If you have a strong core team of seasoned nurses, you probably are not seeing the cultural changes that leaders with significantly younger staff are experiencing. Most executive nurse leaders also don’t have young staff reporting to them, so they, too, might not experience the challenges their frontline leaders have.

I always tell leaders not to do victory laps about their strong team cultures. The challenges discussed above are prevalent today in nursing, and this could be a movie coming to a theater near you in the future that has not arrived yet.

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By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Increasingly, acute care areas are now staffed with nurses with three years or less of clinical experience. Most new graduates today are young, and in addition to lacking clinical expertise, they also lack life experience. Consider the story of an urgent care director who recently discussed this during a program:

Last week, we had a 55-year-old man walk into our urgent center complaining of back pain. He was checking in at the desk when he suddenly collapsed. A code was called, and EMS was notified, but we were unable to resuscitate him. I have several new graduate nurses working in our center. After this happened, I looked around and saw these young nurses crying. They were in shock that a seemingly healthy and athletic man could suddenly die. I asked them about their experiences with death and learned that not one of the three nurses had ever been present for a patient or family member’s death. This was a shocking experience for them, and they had difficulty emotionally absorbing it. We are part of a more extensive health system, so I could access our chaplain service to come onsite and conduct a critical incident debriefing to help our young staff. We have had patients die in the past in our center, but I have never seen the reaction that I did with these young nurses. It made me more aware of things to pay more attention to.

As she told the story, several leaders spoke up about their experiences. One critical care director noted that today’s ICU population is much sicker, and even in the post-COVID environment, they are seeing more deaths. She had recently spoken with one of her new grads, who told her that the ICU was not a happy place and that seeing this many deaths was not good for her mental health. The ICU director noted that she had seen so much death in her career that she had not given much thought to how the environment might be affecting today’s nurses, who are younger with less life experience. She has added a question to her interview to assess how much experience applicants have with death and dying and found the answer is usually little to none.

Right now, health systems are challenged with widespread burnout and psychological distress among nurses that is contributing to staffing shortages that create a cycle of overwork, inadequate coverage, and strained morale. Press Ganey has sounded the alarm about the challenges nurses face today decompressing from their work. This situation becomes even more complicated in environments where acuity is high, and many patients die during their hospitalization. There are few expert nurses on most units today who can help talk younger staff through these experiences. Providing critical incident debriefings when needed helps nurses process their emotions and reset them before they move back into the work environment.

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By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Few nurse leaders would disagree with the need for disruptive innovation in our healthcare systems. Yet, not all innovation works and it can have unintended consequences and high costs. A more immediate return on investment and improvement in productivity for most organizations can be achieved by reducing the friction in the work environment.

Stanford researchers Robert Sutton and Huggy Rao provide some much-needed leadership insight into how to do this in their book The Friction Project: How Smart Leaders Make the Right Things Easier and the Wrong Things Harder. They argue that organizations today are plagued by destructive friction that makes work much more challenging. The authors contend that leaders are the trustees of their staff’s time and should see their roles as “friction fixers.”

The idea of leaders as friction fixers is not new. In 2017, in The IHI Framework for Improving Joy at Work, leaders were urged to identify impediments to joy at work. The recommendation was that leaders should work with staff to identify obstacles in daily work or the “pebbles in their shoes” and then set priorities and address them together. Nurse leaders who used this framework often found that the pebbles in their staff’s shoes were easily solvable problems that would not have been raised had the question not been asked. Fast forward to today, when the pebbles in the shoes of nursing staff continue to grow, leading to high turnover rates, burnout, and increasing frustration.

So why not commit in 2025 to studying ways to reduce the work friction nurses experience daily? For most senior leaders, it has been years since they have worked at the frontlines of care, so you must involve direct care staff in this discussion. The following are examples for leaders to consider to reduce friction in their environments:

• Figure out the value and cost of staff time spent in meetings. Try to reduce the time spent on organizational meetings by 50%.
• Review the number, time of day sent, number of staff included, and length of emails in your organization. Seek opportunities to reduce the email burden.
• Identify places within systems with significant natural friction (such as throughput in emergency departments) and put roles in place to screen, stall, and serve customers as gatekeepers.
• Start a nursing “get rid of stupid stuff” initiative and have a contest where you seek your staff’s best ideas.
• Recognize that as a leader, the more power you have, the less aware you are about the level of friction in your organization because you do not experience it.
• Be aware of the problem of “addiction sickness” to roles or processes, which accelerates friction over time. Adopt a subtraction mindset. When anyone wants to add anything to the role of nurses – it should be a zero-sum game.
• Focus on handoffs between departments and people within the organization, as these are often a source of friction.
• Look at friction points in medication scheduling that make it impossible for things to be done on time.
• Ask staff to track the time spent hunting and gathering equipment and supplies.
• Do polling in your nursing service on equipment breakdowns, workarounds, and malfunctions, and then demand that vendors improve the quality of their products.
• Choose one area in the EHR to reduce the documentation burden for nursing staff that would have the biggest payoff.

Often, interventions designed to reduce friction have low costs but can have an enormous impact. Starting your friction project in 2025 could be the most important thing you do as a leader.

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