Nursing leadership for the new millennium. Essential knowledge & skills.

The major plenary sessions at the NLN 24th Biennial Convention in Miami Beach, Florida, addressed the subject of leadership as an important component of the convention's theme -- The Nursing Renaissance: New Ways of Being, Learning, and Leading. Dr. Maryann F. Fralic spoke to the essential knowledge and skills of nursing leaders. In the November/December issue, we will print the speech by Dr. Patricia Benner, who focused on nursing practice as the basis of leadership. Our topic today is nursing leadership, as both responsibility and privilege. We'll talk about the essential knowledge and skill elements of nursing leadership in a conceptual framework of The Three Cs of Leadership: context -- the characteristics and expectations of the changing health care system within which nursing functions; content -- the essence of leadership; and consequences. What are the consequences when exerting effective leadership within nursing and external to nursing, and, probably more importantly, what are the consequences if we do not? Barry Sheehy has said that what is taking place in health care today is really an epic, even though we may not realize it. Change happens day by day and decision by decision within our systems of care, and we must ask, "How are we managing clinical care and integration of care?" And, very importantly in this environment, "How are we dealing with cost management?" The tenets for the future in health care are universal. The first is money and precise financial tracking systems. That is neither bad nor good but reality. This entails precise identification of personnel cost, composition, competency, and utilization; quality measurement; productivity; cost measurement; and clinical and administrative research. I would certainly add educational research, and the need for constant and accelerated learning. Today's requirements are twofold: to make good clinical decisions coupled with good business decisions. By preparation and education, nurses are not primarily focused on business. This is a new orientation for us, and certainly for us as leaders. Is this easy? No, it is not. Paul Plesek has said that organizations build up lots of antibodies to change. At a panel at an American Organization of Nurse Executives meeting, it was stated that to form a new habit takes three to four weeks. To abort an old habit takes one to two years and a support group -- a humorous comment, but it is sobering to realize how difficult the concept of change is. A wise person has said that people don't fear change, but they do fear loss. I think that is incredibly true. It is the loss of competency that you experience in a changing system, where you always felt very able. What are the new norms in this new context in which rules change daily? In many areas there are radically new care delivery models and radically new payment models. There are far fewer resources, and fewer to come. And precise quantification is expected. There is also far greater accountability required of nurses for clinical and financial outcomes. A fundamental change is that in the old system, the provision of patient care was a revenue center. If you gave a medication or performed a procedure, you sent the payor a bill, and nicely enough, someone paid that bill. Everything you could think to do for patients was revenue and was therefore encouraged. In the new system, in capitated environments, the provision of patient care is expense. For the first time, there must be identification of what the value added is for all actions and interactions for patients. Nursing has to be a part of that, and that is not necessarily bad. In fact, in many areas, it can be a precursor to a higher quality system if done properly. So, we have moved to a new paradigm for patient care where quality and cost are equivalent, and neither is more or less important than the other. Why? All of us, I am sure, could create such a high quality system for patients that we would bankrupt our organizations. …