Did you know that when geese fly in a “V” formation their work is much more efficient than if they each flew separately? By flying in this unique formation, they increase their flying range by as much as 71%. When the goose leading the flight tires, it moves back into formation and another goose takes its place. If a goose falls out of formation, it quickly feels the drag of flying alone and rejoins the flock to take advantage of the power of the goose it follows. Learning how to be in the lead position, how to support and relieve the leader and how to increase work efficiency as part of a team are goose flight skills that nurses can learn and take advantage of.¹

Dramatic changes in healthcare have left many nurses feeling frustrated and powerless. If we as nurses can learn some of the skills that geese use on their long migratory flights, we can individually and collectively influence future changes in a positive direction.

From stability to chaos

Only a couple of decades ago, our healthcare system was significantly less complicated. The majority of patients were treated at hospitals until they were well enough to function independently at home. The hospital bill was sent to a third-party payer, which reimbursed the hospital. An increasing number of hospitals were constructed, each filling with expensive technology and increasing numbers of healthcare staff. Expensive life-saving treatments, innovative surgical procedures, and noninvasive imaging techniques have resulted in the world’s most sophisticated — and expensive — healthcare system.²

To survive in this highly competitive environment, the healthcare industry has moved to market-based strategies that focus on cost containment, patient satisfaction, and quality improvement.² Enter reengineering, restructuring, job redesign, and downsizing, which every nurse has experienced. Reengineering involves a comprehensive overhaul of patient care delivery. By restructuring, an organization analyses processes that can lead to greater operational efficiencies. Through job redesign, components of a specific role are evaluated with the goal of combining tasks to increase productivity. The outcome of these efforts may be downsizing: reducing the number of positions in an organization.²

Increasing recognition exists that nurses who provide direct patient care have a significant potential for providing leadership in healthcare delivery restructuring. But data from hospitals across the country indicate that staff involvement in decision making can be limited and unequally shared with management and administration.³ As a result, healthcare executives have made many financial decisions about how to allocate valuable healthcare resources with limited input from nurses.

Nurses and other healthcare professionals find it difficult to carry out changes imposed from above. Managers bemoan the fact that staff doesn’t share their concern for the organization’s financial viability, and staff complains that management cares only about money. Often, while these standoffs continue, an organization’s financial prognosis continues to deteriorate — a situation one nurse executive refers to as “organizational ventricular fibrillation.”⁴

The impact on nursing

As organizations undergo rapid change, nurses may feel busier than ever, yet their productivity may actually decrease.⁴ Nurses may feel frustrated and powerless or see themselves as victims of some huge unseen system. Consumed by daily problems, nurses may not be capable of talking about — let alone planning for — the future. Nurses experiencing these stresses may question the value of what they do, fracture relationships with their colleagues, choose to leave the profession, and discourage others from becoming nurses — at the very time when a nursing shortage threatens the health of all Americans.

In most healthcare organizations, particularly in acute care hospitals, nursing is the largest and most labor-intensive component, representing about half the annual operating budget.⁵ In addition, much discretionary spending occurs at the unit level, where nurses are the key decision makers about the use of supplies, equipment and linen — items that also have a major budgetary impact. Ironically, many nurses have no way of knowing what costs they generate as they provide care and often lack the economic awareness needed to make cost-conscious decisions.⁵

It is clear that those closest to a task bring a unique perspective to ways of trimming costs. For example, one institution saved significantly on supply costs by limiting IV starts by inexperienced staff.⁵ In many organizations, the voices of nurses who have similar suggestions for improving quality and reducing costs are not heard because they often lack critical leadership skills.

Learning a new skill set

In addition to recruiting nurses to serve on hospitalwide committees, many organizations have established shared governance, a model that places large numbers of staff nurses in pivotal leadership roles to make significant policy decisions affecting nursing practice, education, and patient care quality.⁴ So that healthcare organizations can take advantage of the knowledge and expertise staff nurses can bring to governance and healthcare restructuring, staff nurses must be prepared with a new set of leadership skills.

Nurses can become future-oriented rather than speculating about the future or adopting a “wait and see” attitude.⁶ What the future will bring can be predicted by looking at demographics, technology, and other societal forces. Demographic trends in the United States clearly point to an increasing number of older people needing care and a decreasing number of nurses prepared in geriatrics to direct their care. Another major trend is the increasing pace of scientific knowledge. Medical knowledge is now doubling every eight years, and 85% of the information collected by the National Institutes of Health is upgraded every five years.⁷

Trends that soon will affect your work include the replacement of traditional patient care “routines” by best practice processes that are outcomes-related and research-based, and an evolution of nursing practice from “fulfilling every patient need” to a model that is realistic and responsive to limited resources. Although you might not end up being a “nurse futurist,” learning more about projected trends will equip you to deal more effectively with system changes.

Seeing the big picture — “Seeing the big picture” is the ability to analyze how a specific situation is connected to other aspects of a broader situation.⁸ Because nurses have not always been included in decisions affecting patient care services, we have a tendency to look for a quick fix without considering the larger picture. Recent research on nurse staffing shows that the numbers and percentage of professional registered nurses in the skill mix has a significant positive effect on patient outcomes.^9,10 Focusing only on mandatory staffing ratios does not automatically ensure better patient outcomes or increased nursing job satisfaction. “More” does not necessarily mean “better.” It is important to have a high percentage of registered nurses, but the skill mix and quality of the staff, their clinical competence, and their ability to critically analyze problems and make appropriate decisions also have an impact on providing high-quality care.⁸ A person looking at a bigger picture is able to look beyond the immediate problem. The shift length, staffing mix, reimbursement criteria, and type of delivery system all have a major impact on appropriate staffing. Simply changing the number of staff per patient may not be the only or the best way to provide safe and effective patient care.⁹ In addition to citing improved nursing ratios, nurses report that their job satisfaction is related to issues such as the quality of nurse-physician relationships, compensation, information technology, and the opportunity to use nursing knowledge to improve patient care.¹¹

Sometimes, an action taken without considering the bigger picture may fix the immediate concern, but in the long term will not solve the root issue — or it may even create other problems.⁸ Leaders are able to see beyond quick fixes; they are more system focused. They’re able to think about the whole, knowing that everything affects something else, and they’ve learned how to ask the right questions.⁸ People who see the big picture don’t become bogged down in task-oriented practice; instead, they implement tasks and care interventions directed toward specific outcomes.

Communicating persuasively — Nurses are often great listeners; we listen eloquently to patients and families. But when it comes to participating on a shared governance committee or a task force with other professionals or presenting ideas to management, many nurses need help. In an interdisciplinary group, nurses, who often have the most relevant information, are often the least verbal. To act powerfully, staff nurses must particularly improve their ability to communicate with administrators and colleagues. Using judgmental words, failing to reason out a position adequately, or speaking too fast or too slowly can all be barriers to effective communication.¹² In addressing our needs, we often spend considerable time providing anecdotal information and minute details about problems affecting patient care while administrators are listening for a large picture to develop. Nurses also need to learn how to focus on major issues and give up “sweating the small stuff.” The goal of communication, whether oral or written, is to create understanding, and the level of understanding increases directly in relationship to the clarity of the message and the way it’s delivered. Staff nurses need to develop skills in making clear, organized presentations that are delivered confidently and in writing memos that get results because they communicate in a way that gains attention and support.

Viewing change as an opportunity — Times of great change are also times of great opportunity because organizational resistance to change temporarily lessens. As nurses, we need to learn how to view the many “problems” of organizational restructuring as challenging opportunities to improve care for patients and work conditions for nurses.¹³ The same emotional responses that patients and families go through in response to personal health crises apply to nurses when we face organizational change.

Fortunately, you can learn strategies to see the opportunities inherent in change. Start with becoming involved with the change so that you have some influence over what will change and how the change occurs. If you have no ability to influence the change, resolve to focus less on grieving for what you’re losing and instead start focusing on some positives that will result from the change.¹⁴ If the change in question is particularly difficult, consider that none of us can control changes that occur naturally in life, and it is not realistic to expect that there will be a return to a more stable healthcare environment.¹⁴ Before, during, and after the change process, stay fit and healthy by eating right and getting sufficient exercise and rest.¹⁴

Being proactive rather than reactive — Nurses often wait for events to overtake them and then react rather than anticipating problems and taking a proactive stance. Frequently, instead of acting proactively, we blame those in executive leadership positions or “the system.” We eat our young, often don’t collaborate with others, fail to capitalize on our knowledge and experience, and may describe ourselves as “just a nurse.” Every nurse has a vision for a better world for patients; whatever your vision is, it’s important that you don’t sit back and wait for someone else to make something happen. Each of us must have passion for our little corner of the nursing world. You don’t have to be a position of authority to advocate for needed change, to raise issues, and to gain support for your ideas and to speak clearly and strongly about possible solutions. If you’re not satisfied with an issue in your work setting, you can complain to your colleagues, blame administration or someone else — or create positive change. The professional nurse who is a leader will always do something more than just complain. As practicing nurses, we all share accountability to create solutions for the problems we encounter.

Every nurse as a leader

As new graduates, we all begin our nursing careers in a “followership” position. With time and experience, this should change; however, many nurses depend on their nursing administrators to provide all the leadership that nursing needs in an organization. Yet, nothing could be further from the truth. Some of the most powerful leaders have no position of authority in an organization, but are able to successfully point the way to both small and large improvements in patient service delivery. Leadership is directly related to “real nursing” — staff nurses must exert leadership in order to fulfill their responsibility as patient advocates and to help design a more effective healthcare system that will benefit individuals, families, and communities. As one nurse executive puts it, “Nurses must understand how to lead in order to understand how to nurse.”⁸ It’s important to view leadership as not about power, but about acting powerfully.⁸ Leadership is not an inborn ability but a set of skills and qualities that can be learned and enhanced over the course of your career. Registered nurses can no longer conceive of themselves as “just nurses.” Whether you’re a staff nurse or the vice president of nursing, it’s vital to be self-confident, to have high professional self-esteem, and to be visionary.⁸ As individual nurses, we tend to focus on daily tasks within a designated shift. Because of this, some nurses act as passive followers rather than as leaders and remain in positions in the organization that are less powerful. One of the most influential people to take the lead was Florence Nightingale. She had a mission, her timing was right, change was desperately needed, and she had the skills to be a leader. She was also intelligent, resourceful, strong willed, and not willing to take no for an answer — qualities you and your nursing colleagues all have.⁸ Just like the flying geese, we must learn to share leadership and must all take our turn dong the work that will help our patients recover, our profession evolve, and our organizations thrive. Every member of your nursing team has the potential to fly the point position and serve as the leader.⁸

The power of supportive followers

In today’s flatter, leaner organizations, leaders cannot survive without committed, engaged, contributing followers.¹⁵ Being a leader and being a follower are separate roles that complement each other. There can be no leaders without followers, and there can no be no followers without leaders.⁸ Being a good follower takes special talents, just like being a good leader does.¹³ Leaders need to count on followers to provide input that focuses on finding solutions, not just identifying and complaining about problems. Followers can support leaders by asking questions, giving thoughtful feedback, working to achieve group goals, and providing encouragement when the leader takes a risk on behalf of the group.¹⁶ Being an effective follower is not a passive position; the follower must think critically about the leader’s ideas and opinions, have the skills to advocate with others for those ideas, and take an active role in providing support to the leader. Exemplary followers are those who can function independently, who think critically about ideas that are proposed or directions that are suggested, and who become actively involved.⁸ Effective followers challenge the ideas and opinions of leaders, suggest alternative courses of action, and invest time and energy to arrive at the best possible solutions for the group.⁸ It’s important to realize that effective followers thoughtfully criticize the leader’s ideas; they don’t just complain and withdraw.^8,17

Alienated, passive followers

Other types of followers are less supportive. Alienated followers may consider what the leader is proposing, but remain passive and withdrawn. They may continue to complain about the ways things are done, but rarely invest the time or energy to suggest alternative approaches.⁸ “Yes” people are those who are eager to take orders, defer to the leader, and thrive on a great deal of order, structure, and predictability. They are often uncomfortable with making decisions and rarely raise questions or challenge the group. Passive people are dependent and go along with whatever they are told to do. Easily led and manipulated, they need a great deal of direction and never go beyond their own work assignment. They are unable to commit themselves to the larger goals of the group. What nursing needs now are more exemplary followers. Blindly following a leader without thinking or questioning or taking a passive backseat role at work will do little to advance the nursing profession, promote individual growth, or enhance quality patient care. Nursing needs followers who have many of the same qualities leaders have — a willingness to serve, assertiveness, determination, the ability to challenge ideas, courage, the ability to act as change agents, and openness to new ideas and perspectives.⁸

Taking action

All nurses can have a profound influence on finding the best ways to deliver high-quality healthcare at an acceptable cost. To achieve this goal, each of us must ask ourselves what we are personally doing to improve ourselves as individuals and to improve nursing.⁴ To develop and exercise your leadership potential, convince your administration that you need a leadership course for staff nurses in your organization and volunteer to be on the committee that organizes it. As you improve your skills in problem solving, critical thinking, and communicating, seek out other nurses whom you can mentor. Learn how to lead, how to follow, and how to use your knowledge and experience to act powerfully. And, the next time you see a goose migration, think of the possibilities for nursing.