Leading the Leaders

Nurses appreciate when people acknowledge our opinions and professional judgement. Sometimes in healthcare we need to lead our leaders to that understanding and acknowledgement. We have all the tools we need. Let’s take two hypothetical examples:

Oncology patients are often vulnerable to spread of infection due to their immunocompromised status, and oncology nurses are vulnerable to exposure to toxins in the workplace from chemotherapy administration.

• An oncology inpatient unit experiences a high rate of Clostridium difficile infection rate, part of a larger pattern of similar infection in other units. As a result of a big push several years ago to distribute hand sanitizer throughout the hospital and in each patient room, alcohol gel continues to be used at a higher rate than handwashing. Recent evidence shows alcohol is ineffective at killing this pathogen, while handwashing is effective.
• High levels of chemotherapy residue have been found in an outpatient chemotherapy infusion room. The administration recently decided to use volunteers to clean the patient areas in all the outpatient facilities during the day.

One of the frustrations for nurses and other healthcare workers is when a problem arises at the patient care level and a solution is needed quickly. Most hospitals are now part of big healthcare corporations. The bigger the organization, the more complex and bureaucratic the decision-making process becomes. Decisions are made far away in a remote office by people who might never have set foot in a room with a direct patient caregiver.

Leadership consists of people who ensure things work as efficiently as possible so the organization gets full reimbursement from payors, keeps infection rates down, runs as lean as possible, and shows profit and growth. From their perspective, alcohol gel keeps staff in compliance with handwashing and is more efficient, while volunteers can replace paid staff to clean.

When the organization claims to support evidence-based practice, hold them to it. Sometimes the evidence supporting the organization’s pursuit of the bottom line might not be the best for patient safety. If high-tech, expensive, and complicated solutions are suggested before thinking about basics, it’s because those in leadership have little idea of the process on the ground.

When the organization claims to be providing the best cancer care, hold them to it. Cancer care is a big draw to healthcare facilities, as are associated marketing expenditures. Platitudes about caring coming from marketing people rarely match the organization’s level of understanding of what it takes on the ground to provide that kind of care. In almost all cases, we already have everything we need to solve problems.

In the two examples above, solutions come down to hands, feet, eyes, and ears; tools we already have, that don’t cost us anything. The hard part is getting everyone, including leadership, to use those tools. Nurses use them all the time. We need to remind the leaders how to use them. Here’s how:

Eyes: Read and present the evidence again. If handwashing is more effective, even though the hospital already made the change and investment in hand sanitizer, instead of the expense and trouble of monitoring everyone’s use of gel or handwashing, they need to admit the evidence has changed. It’s time to shift the culture back to handwashing, and provide education. Present the evidence of cancer patients’ vulnerability to infection, and evidence of costs of those infections.

Ears: Listen to the staff on the floor, they are too rushed going in and out of rooms and a quick squirt of gel has become a habit. When staff say they are too busy to attend meetings, listen. Staff can’t attend meetings because there aren’t enough of them to leave the patient floors. Go to them, where they work, to listen. Hold a moving meeting, or suggest a retreat across levels of the organization where equal numbers of floor nurses are on equal footing with management. Implement their suggestions.

Feet: Do the footwork to shadow nurses to find out why they are too busy to attend meetings or to wash their hands instead of using gel. Leadership needs to get out on their feet, dress in scrubs, don personal protective equipment, and shadow a nurse for an entire shift. They should wash their hands each time they enter and exit a room, as well as whenever the nurse’s hands become contaminated. Then they will see how that impacts the time needed to do all the other nursing tasks with a full patient load and being called from room to room. When the nurse is caring for a patient, they should listen to what the patient needs, and what the nurse does to meet that need.

Hands: In addition to washing their hands, leadership needs to lend a hand. Learn how chemotherapy contamination and pathogens spread, and the skills and techniques to properly remove them. This requires adequate time for handwashing, sanitizing, and not omitting steps, which requires adequate staffing and training.

All it takes is for leaders to watch, listen, walk, and lend a hand. They should always try these simple tools for solutions before high-tech, expensive ones. If they are too busy to get out of their suits for a day and see how the things they mandate impact nurses and patients, then they have no business being in a position of leadership. You cannot lead if you have never followed.