Nursing Leadership Challenges in 21st-Century Healthcare

Introduction: The Changing Image of Nursing

When considering the challenges of the health profession in the 21st century, a pointed quote from former Health and Human Services Secretary Donna Shalala and Linda Bolton, Head of Nursing at Cedars-Sinai Medical Center, comes to mind:

"The image that people often have of nurses as acute care handmaidens… is so out of date and inaccurate that it may impede the nation's ability to harness the expertise and vision of these professionals in ways that can produce the needed improvements in the quality of health care… The evidence is clear that we must shift our focus to the care that individuals and populations need to improve and protect their health, whether it means changing the way nurses are educated or addressing the interprofessional competition that results in resistance to the full utilization of nurses" (Mason et al., 2011, p. 401).

This may seem a somewhat cynical statement, but when one examines the statistics for nursing shortages, the demographics of an aging population, and the clear importance of healthcare professionals in the era of the Affordable Care Act, nurses are more critical than ever before. Registered nurses constitute the largest healthcare occupation, with almost 3 million job openings as of 2011, 60 percent of which are in hospitals (U.S. Department of Labor, 2011). The professional nurse of today must also face a number of significant challenges: a highly charged political environment, budget reductions, changing reimbursement packages, staffing shortages, and fast-paced technological advances. Even more significant is the pace at which the modern nurse must strategically anticipate the future needs of the healthcare system. No longer is it feasible for the professional nurse to be anything other than a highly competent and energized leader (Schmidt, 2006).

The American Organization of Nurse Executives defined the core competencies of nurse leaders as: (1) communication and relationship building, (2) knowledge of the healthcare environment, (3) active leadership, (4) professionalism, and (5) business skills (AONE, 2005).

Core Competencies and the Modern Nurse's Role

From a personality perspective, a registered nurse combines clinical knowledge with the subjective dimensions of empathy, communication, understanding others' reactions, and problem solving — representing a more multidimensional approach to viewing the patient in a holistic, rather than purely disease-based, model. Modern healthcare and nursing are more complex than ever before. The nurse's role is far more than that of a simple assistant; it requires the understanding and application of a large and varied skill set to address many different situations within any given period of time.

There are two primary ways of approaching an interdisciplinary issue within modern nursing: (1) preparation and expertise, and (2) leveraging other human resources. In the first approach, preparation might include coursework in psychology, communication, ethics (philosophy), anthropology or sociology (for working with diverse populations), and business issues such as budgeting and scheduling. In the second, it is important to take an active and contributing role within an interdisciplinary team, since we now view the client — the patient — in a more holistic manner. This includes being part of the team that addresses mental health issues, family or social situations, health literacy to understand procedures or medications, specialist consultations, general care, advocacy, and above all, helping the patient take some responsibility for their own healthcare as a partner in the process of becoming well (Borkowski, 2011).

Another important dimension of modern nursing is that it encompasses both covert and overt leadership — often referred to as servant leadership. In brief, servant leadership is a philosophy of providing opportunities for others to succeed by making situations easier — finding ways to support others and helping to prevent previous mistakes or errors from recurring (Clark, 2009).

The interdisciplinary nature of today's healthcare environment demands that nurses work collaboratively across professional boundaries. Mental health professionals, social workers, pharmacists, physicians, and nurses must all function as a cohesive team in order to provide truly patient-centered care. The nurse's unique position — present with the patient more consistently than almost any other provider — makes her or him an essential coordinator of this collaborative effort. Critical thinking is also central to this role; the ability to assess complex situations, evaluate evidence, and make timely decisions is indispensable in modern clinical practice (Critical Thinking Company, 2013).

Interdisciplinary Practice and Servant Leadership

We must add to these challenges the very real demands of time required to develop leaders who can teach effective courses to nursing students while remaining active in scholarship and clinical practice (Ashcraft et al., 2007). Additionally, remaining professionally involved in clinical care while simultaneously taking on a leadership role in academics requires a great deal of passion and commitment to a demanding environment — a genuine disposition to become a change agent (Adams, 2007).

Is this a daunting time for the professional nurse? Are the challenges seemingly overwhelming at times? Are we, as a nation, at a critical juncture in the nursing profession? The answer is an overwhelming yes. However, upon reflection, what better time could there be to be in a profession positioned at the locus of change, with the ability to become part of the change paradigm itself?

This moment in nursing history calls to mind the story of the Hundredth Monkey, which has many permutations relevant to the profession's current situation. In brief, scientists were studying snow monkeys on the islands of northern Japan — monkeys that ate sweet potatoes growing near coastal bog waters. One day, on Island A, one of the scientists pulled up a potato to eat as a snack. Covered in muck and sand, the scientist washed it off in the ocean. Unbeknownst to the scientist, a dominant female monkey was watching, and later that day she also washed her sweet potato. Soon, all the monkeys in her tribe were washing their sweet potatoes — the potatoes likely tasted much better clean and salted from the seawater. For argument's sake, suppose there were 100 monkeys on Island A. Oddly, when the 99th monkey taught the 100th monkey to wash its potato, monkeys on Islands B, C, and D also began washing their potatoes.

This phenomenon is extremely relevant to the nursing profession in the early 21st century. However one chooses to define it, it has happened again and again throughout history: once enough people imagine something, it becomes real. It may mean technological change, spiritual change, attitudinal change, or some combination of all three. This is an exciting prospect in relation to nursing leadership, because we can ensure that somewhere we touch that hundredth monkey — the tipping point that will forever change the paradigm of nursing. It may happen through spiritual ministry at a hospital or care center, through work on a busy ward, or through coaching and guiding the next generation of nurses so that they, too, can help find that hundredth monkey.