Journal of Nursing

Clinical Nurse Leadership and Performance Improvement on Surgical Unit

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by Cheryl A. Landry RN,MSN,CNL(c) witland@cavetel.net
Tags: clinical nurse, leadership, performance, surgical unit
Abstract
There are many ways that nurses can prevent harm to their patients. One method is to provide
the necessary care that will promote only positive outcomes for their patients. Performance
measures of the surgery unit that were identified and could be measured were antibiotic usage
and venous thromboembolism prophylaxis. To effectively transform the nurses thought
processes and gain buy-in to this performance improvement a cultural change was identified.
The nurses needed a Clinical Nurse Leader (CNL) to assist them in understanding the need for
this change and the benefits that would come about once this change was implemented. The
CNL is a transformational leader who uses more than one style of leadership to get their
employees to perform at a level of excellence. The styles of leadership used to adequately
improve the performance on the surgery unit were affiliative and democratic.
Within every healthcare organization there must be at least one leader who has wisdom, a
sense of right and wrong, and a vision for the potential of the organization. The vision of the
leader must be embraced by the employees; the vision must be pertinent to their cause. Not
only must a leader have a vision, so should the Clinical Nurse Leaders (CNL), they should also
have exceptional interpersonal and communication skills that are necessary for a leader to be
successful (Manion, 2005). The success of a leader is measured by the positive influential
ability to get employees to reach the same goals of both the leader and the organization.
Another way of assessing a leader is by the leadership style used to direct his employees.
Leadership styles arise from leadership theories. Within this essay a description of the
leadership style, characteristics, and role effectiveness that each leader must have will be
discussed. There will also be a discussion of performance improvement and how
transformational leadership can change a culture of noncompliant nursing staff to promote
performance excellence within an organization.
Wheatley (2000) stated we have sought prediction and control, and have also charged leaders
with providing everything that was absent from the machine: vision, inspiration, intelligence, and
courage (p. 1). A new era has brought innovation to the minds of leaders and employees. A
leader establishes a vision, autonomy, encourages esprit de corps, and empowers employees
to think critically (De Pree, 2000).
When leading, two leadership styles are used. The style of leadership used depends on the
situation. Mills (2007) stated Goleman observes that leaders who achieved the best results
used a variety of styles, which they adapted to the situation (p. 129). Two styles of leadership
that an effective leader may use includes: democratic and affiliative. These styles of leadership
are based on the transformational leadership theory.
Democratic Leadership Style
The democratic style of leadership allows the employee to take part in goal setting and the
decision making process. Information or suggestions received from employees is taken into
consideration and used when feasible. The democratic leader although, allows for input from
employees, the final decision is made by leader. However, when a particular area or topic is
unfamiliar, the democratic leader is receptive to ideas and suggestions (Mills, 2007). The
democratic leadership behaviors that enhance effectiveness includes: encourages others to
take part in the decision making process, develops skills of employees, allows the team
members to be in control of their own work receiving the kudos deserved; this motivates
members of the team to work harder (Krause, 2007).
Affiliative Leadership Style
Mills (2007) stated leaders put their people first. This leadership style is generally considered
positive and is especially useful when attempting to build esprit de corps among team members,

increase morale of rebuild broken trust (p. 133). The behaviors associated with this style of
leadership includes: a positive approach to employees, passive and prefers not to anger team
members, waxes and wanes when it comes to making a decision. The leadership behaviors of
an affiliative leader may enhance or hinder team effective. Putting the team members first and
taking into consideration that all assignments are completed on time and the team members are
satisfied with the contribution of the leader is very important. As an affiliative leader, these
behaviors may also hinder the teams effectiveness. The negative behaviors include: the
leaders desire to not anger team members. This passive behavior will inhibit the leader when it
is time to correct employees who do not follow the instructions given them, or fear of critiquing
an employees contributions. The affiliative leader will also find it difficult to make a decision or
make a choice at a critical time.
Transformational Leadership Theory
The transformational leadership theory is the basis for optimal leadership styles. Krause (2007)
stated the developmental nature of this style helps leaders achieve results by influencing,
motivating, and inspiring employees over whom they may or may not have direct supervision
(p. 1). Both the democratic and affiliative leadership styles influence, motivates, and inspires
employees. Following the transformational leadership theory and exhibiting the behaviors of
both a democratic and affiliative leader will continue to allow for leadership effectiveness.
According to Piccolo & Colquitt (2004)
Transformational leaders have the ability to raise follower task performance while also
encouraging organizational citizenship behavior-those extra-role behaviors that are not
discretionary and not directly recognized by an organizations formal reward system and that
help improve organizational functioning (p. 1).
As a transformational leader, if the employee is able to relate to the mission and vision of an
organization, the employee will play a large part in the positive efforts toward building the
organization and be personally rewarded for its success.
Performance Measurement
Hall, Doran, & Pink (2004), suggested that valid indicators of hospital quality are based on
outcomes of care experienced by the patient, the nursing staff and the hospital system (p. 1).
One effort in question is the measure of performance of the nursing staff who utilizes nurse
indicators. These indicators are specifically designated for the surgical unit of any hospital that
has an operating room. The focus for this essay will be the Washington, DC Veterans Affairs
Medical Center (VAMC), the unit of interest will be 2D General Surgery.
Quality Control
According to Marquis & Huston (2009), quality control, a specific type of controlling refers to
activities that are used to evaluate, monitor, or regulate services rendered to consumers (p.
538). The quality control relevant to the surgical unit requires a plan for ongoing monitoring,
auditing, and evaluating of findings that will provide a basis for performance improvement. The
Agency for Healthcare Research and Quality (2005) stated the Surgical Care Improvement
Project (SCIP) is designed to provide hospitals with effective strategies to reduce four common
surgical complications-surgical wound infections, blood clots, perioperative heart attack, and
ventilator-associated pneumonia (p. 1). The interventions used to combat these surgical
complications are evidence based practices and as time goes on changes will occur to improve
the outcomes of surgical patients.
Indicators
Surgical complications can take a measurable toll on a patients health and safety causing
prolonged treatment and increased lengths of hospital stays. To prevent these complications
specific measures are performed that will aid in the recovery of the patient. Two performance
measures that will be focused on include appropriated antibiotic usage and venous
thromboembolism prophylaxis (VTE). These two measures were chosen because the nursing

staff plays a crucial role in the compliance and the effectiveness of both antibiotic and VTE
prophylaxis usage.
Benchmarking
To have performance excellence with the two previously stated measures there must be a
reason to look at them. Hall, Doran, & Pink (2004) also suggested that The outcomes of
nursing care should demonstrate three characteristics: (1) they should be measurable by
efficient, valid, and reliable methods; (2) they should be relevant to the patient, healthcare
setting, and or government; and (3) they should be represent the intended or unintended effects
of hospital nursing care (p. 1). If the data shows that the performance is less than perfect than
there is room for improvement. If the data shows perfect performance then there is no reason to
routinely look at this measure, random monitoring will therefore be required. Next, a benchmark
is performed. Marquis & Huston (2009) defines benchmarking as the process of measuring
products, practices, and services against best performing organizations (p. 540). When
benchmarking the SCIP performance will be reviewed. The review will assess how well or how
bad they are doing and then goals will be set to reach and surpass the other organizations
performance. Surpassing the benchmark will require the VAMC to set their SCIP performance
numbers higher than that of the benchmark.
Auditing, Processes and Tool
The process is initiated with an audit tool which was specifically designed to meet the needs of
the quality control. The tool has information that is relevant to the data that is being collected
such as the patients name, type of surgery, date of surgery, diagnosis, antibiotic order, antibiotic
order followed, VTE ordered, VTE order followed and comments. The bottom of each column
will be totaled once the sheet is completely filled out. The information used to complete the audit
sheets is obtained from different sources. The majority of information is obtained from the
Computerized Patient Record System (CPRS). The CPRS contains physician orders, operative
notes, nurses notes and medications, all of which are needed to complete the auditing process.
Once the orders of new admissions are reviewed the patients are physically assessed to ensure
that the orders have been accurately carried out by visualizing that the patient is wearing TED
hose and SCD pumps.
Data will be collected daily for all new admissions for the first quarter (October 2008 to
December 2008). This data will prove to be a baseline for future data collection. Future data
collection will be done on a specific number of randomly selected patient charts. The data will
be analyzed for discrepancies, patterns, and identification of staff members who needs
additional education.
The desired healthcare outcomes should be comparable to the background and knowledge
base of the nursing staff. This is not to say that quality care cannot be achieved without
outcomes being obtained. Staff can deliver poor care and quality of performance may be
deemed as excellent. There are many indicators of quality care and outcomes measurement is
only one. To use outcomes alone to measure quality care will produce data that is not valid and
unreliable (Marquis & Huston, 2009).
Integrating Leadership
To produce the quality of care needed to be considered an organization of excellence, a
transformation of the culture of nursing staff must take place. This transformation must be one
that promotes autonomy, and integrity. In order for the nursing staff to achieve this new behavior
they must be led by a leader of change. If the CNL is to aid or lead the way in the transformation
process there must first be a belief in their own mission, vision, roles and implementations for
performance improvement. There are many roles that a leader must take into account and have
the capability to live up to them. There is no contract that can be written that will eliminate all
risk of integrity loss. A baseline requirement for leaders working to build a unit or organization is
a necessary requirement. The staff may not understand every aspect of how or why the system
is being developed, but if people believe that the leaders are honest and have their best
interests at heart, they will generally be willing to support change. Conversely even the most

brilliant scientific proposal will fall flat if led by an individual who is not regarded as having the
highest integrity.
Marquis & Huston (2009) suggested the leadership roles include:
1. Encourages followers to be actively involved in the quality control process.
2. Clearly communicates expected standards of care to subordinates.
3. Encourages the setting of high standards to maximize quality instead of settingminimum
safety standards.
4. Embraces and champions quality improvement as an ongoing process.
5. Uses control as a method of determining why goals were not met.
6. Distinguishes between clinical standards and resource utilization standards, ensuring that
patients receive at least minimally acceptable levels of quality of care.
7. Supports /actively participates in research efforts to identify and measure nursingsensitive
patient outcomes (p. 538).
Once the staff recognizes that the leader is one who holds all of these attributes, the leader will
gain the trust of the staff and will then have buy-in into the performance improvement strategies
that will prevent negative outcomes. Marquis & Huston (2009), suggested that inspiring
subordinates to establish and achieve high standards of care is a leadership skill. Leaders role
model high standards in their own nursing care and encourage subordinates to seek maximum
rather than minimum standards (p. 539).
Outcomes of Performance Measures
The first data collection from the surgery unit was completed for the month of October 2008.
The data showed that there were 76 admissions to the unit, 57 of these patients were surgical
patients, and 19 patients were admitted for other reasons such as testing, observation, surgical
workup, and overflow from other units. 30 patients required anticoagulant orders, and 46
patients required antibiotic orders, and 38 patients required TED and SCD orders. Only seven
patients were ordered antibiotics that were administered improperly. The errors discovered in
the data collection of the seven patients revealed that they received too many doses, too few
doses or the doses were held causing a delay in the care of the patient. The other data that was
collected was evaluated and deemed free of mistakes.
Action Plan to Improve Performance
Because the data collected showed that the errors were in part due to nursing negligence,
education of the nursing staff is a major part of the action plan to improve performance of
antibiotic usage. Education will include the purpose of collecting the data on antibiotic
administration, the importance of antibiotic administration and the consequences that arise
when the medication is not administered or administered improperly. Each month the data will
be presented in the performance improvement meeting and disseminated to all of the committee
members. Either this data will show an increase in compliance, a decrease in compliance, or
here have been no changes in compliance. This information will be posted on the unit to show
how well or how poorly the staff compliance has been; hopefully this posting will spark a drive in
the staff to be strive to do better. Octobers data is the baseline for the months to follow, all data
collected after October hopefully will show a decrease in errors of antibiotic usage.
Evaluation
An evaluation of each months data will be discussed in the monthly staff meeting. No matter
how well or how poorly the staff is doing, there will always be room for the staff to improve their
performance. During this meeting attempts at nursing empowerment will be made by giving
positive feedback and reiterating the necessary mindsets that are needed and welcoming the
behaviors of staff that support quality and productivity (Marquis &Huston, 2009).

Conclusion
It is extremely important for all disciplines in the hospital work together to provide excellent care
to the veterans of the VAMC. For all staff members to actively take part in SCIP there must be a
transformational leader who utilizes the many attributes needed to motivate the staff towards
excellence, instill autonomy, and empower the staff to think critically. Gilkey (1999) suggested
that four major initiatives will be prominent in nursings journey toward to the future. They
include nursing professionals relationships with physicians and other health professionals; the
way the profession meets its accountabilities to the public, the composition, and development of
the nursing workforce, and the adaptation of nursing science to changing practice (p. 5).
The changing practices include the CNL encouraging and pushing nurses to become actively
involved in shared governance and becoming responsible for the roles that they play on their
units. These nurses must recognize that nursing is changing from just patient care and many
more tasks are being expected of the nursing staff to accomplish. Effectiveness in performance
measures and excellence after performance improvement will paramount in the nursing leaders
role. The nursing workforce is made up of many cultures, ages, and educational backgrounds.
Diversity will continue because nursing will be in the mainstream of education.
The incorporation of performance measures and quality outcomes in tomorrows basic nursing
curriculum will only further prepare the nurse for a rewarding career.
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