Watching the Signposts - Emerging Nurse Leader

Future By Rose O. Sherman, EdD, RN, FAAN

Last week was nurses week and I had the privilege of presenting to three nursing leadership teams at hospitals in our area. In asking the nurse leaders about their challenges, they talked about the perils and opportunities involved in leading during a time of health reform and change. One CNO observed, “it can be hard to know if we are doing the right thing………we are putting together a puzzle without all the pieces in place.” This is a great metaphor for an environment where the rules seem to keep changing. Dr. Tim Porter O’Grady talks about the importance of leaders as good signpost readers. Leaders need to have both a predictive and adaptive capacity. This means that we need to be aware of change and how it may impact the interface between the environment, the organization and the staff.

How to Watch the Signposts

Watching the signposts to forecast how change could impact your environment can be tricky but there are strategies that you can use to help you to more effectively make these assessments:

1. Read more broadly with special attention to political, business and demographic trends.

2. Pay attention to the discussion of a wide-range of experts especially those who may hold viewpoints different from your own.

3. Reflect on a number of different scenarios both positive and negative of how a change might impact your organization or environment.

4. Challenge your own assumptions and be prepared to be wrong.

Example of a Signpost Analysis

This morning, I picked up my local paper and the lead story involves a new Medicare pilot project that would expand hospice options by not requiring the “no cure mandate” or six months of life certification upon entry into hospice. This initiative is being described as potentially a fundamental change in the way health care is delivered and an expansion to the discussion of end of life care. Currently 1.6 million people receive hospice care annually and most of that care is given in the final weeks of life. Many people are reluctant to give up curative care when terminally ill and don’t enter hospice until their final days. This pilot project would allow patients to have both options. They would be followed by hospice and given a certain level of service but also have complete access to curative treatments. The hope is that patients would choose hospice earlier if they did not have to make an all or nothing decision. By choosing hospice, they could feel more comfortable with end of life discussions and might eventually elect full hospice services at a much earlier point in time. If this happened, then healthcare costs at the end of life might go down. Economists at the Centers for Medicare and Medicaid estimate that more than 25% of Medicare spending goes to the five percent of beneficiaries who die each year .….most of this spending is in the last three months of life, often in intensive care units.

The Trends – Three million Baby Boomer are turn 65 each year and become eligible for Medicare. With Medicare costs skyrocketing, it is not surprising that policy experts would look at pilot projects like this one.

The Expert Opinion – Expert opinion on the this project is mixed. Some experts predict extensive Medicare fraud especially with so many for profit hospices in the US today. Other healthcare economists believe that this project could pave the way to important end of life care discussions that need to happen in the US today, and potentially reduce costs.

Impact – Depending on the case mix of the population that your organization serves – this project could substantially reduce inpatient hospital days particularly in intensive care unit settings. More end of life care would happen in the home or skilled nursing facilities. Reduction of aggressive end of life care could reduce the professional moral distress that health professionals feel when they participate in what they consider futile end of life care. OR – there may be no change at all if patients continue to elect the mixed option of both curative care and hospice.

Challenging Assumptions – It is possible that another very different scenario could emerge that I am not even considering because of my limited frame of reference. There could emerge a whole new industry outside of traditional healthcare for end of life sherpas or guides using complementary holistic care approaches.

Nursing staff often want a level of certainty about the future that as nurse leaders – we cannot give them. What we do owe to staff is to help frame the change for them. Talking about signposts at staff meetings can be an excellent way to get staff more comfortable with change and thinking about the future.