Maryann F. Fralic, RN, DrPH, FAAN

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• #1. Competency: Quantification
• #2. Competency: Deliberation
• #3. Competency: Communication, executive style
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There are many kinds of nurse leaders. Some are very operational and internally focused. Others are operational but are also constantly looking for the answer to “what's next?” Maryann Fralic is one of those leaders who have the uncanny ability to look into the future and prepare current leaders for the next reality that she sees. In this interview, she is asked about how she learned those skills and what her advice is for leaders of the future.

People think of you as a Yoda, a Wise One who is all knowing. How did you get that way? Did you always have these skills?

Nice to hear, but I certainly am not all knowing. What I try to be is reflective, to always look for the bigger picture, to see the confluence of issues and the consequences of events on the future. To anticipate the unanticipated. To look for the familiarity and patterns in what is occurring. To ask what happened in the past and how may it impact the future. To create “what if” scenarios and to do active scenario planning. To diligently focus on the strategic visioning that today's nonstop environments demand. I didn't say I can do all of this, but I certainly try!

You have always chosen to keep your feet in both worlds of clinical care delivery and academia. Many nurse executives do not choose that path. What has this done for you, your career, and the profession of nursing?

I know of no other way. My nurse executive roles in the service sector have always included an academic appointment by design. That permits me to influence—and be influenced by—the academic arm of clinical practice. We must be an integrated profession, not one of parallel functions. Since the components of professional nursing are education, practice, and research, one must inform the other. We really cannot be insular in one camp, pointing out the deficiencies in the other. That is not the way a true profession operates.

A wonderful friend and mentor, Loretta Ford, the founder of the nurse practitioner role, sent me the following relevant thought from William R. Allen, and I have adapted it for emphasis: “Research [and education] is to practice what sin is to confession. Without one, you have nothing to say in the other.” We are learning that lesson well as we increasingly adopt a scientific evidence base for our practice.

But how do we know what both sides must do? How do we do this together? What is the best way to prepare contemporary nurse professionals to think, to reason, to adapt to the incessant change in the world of health care? To deliver quality care despite ever diminishing resources and relentless new demands? To learn to think and not simply to do? All of this is clearly leadership work that we must do together as respected and valued partners.

You have been characterized as someone who can “see around corners,” look into the future, and build programs now to meet the future challenges. How have you prepared yourself to do this kind of work, and how do you sustain yourself in this rigorous kind of activity?

I don't know if I really do that, but I certainly try. Two things come to mind.

First, read the right things. You must have a systematic program to review those key sources that you faithfully read all of the time. Start by selecting the most important sources of information in your field and in related or even unrelated fields. For example, The Wall Street Journal and Harvard Business Review are must-reads for me, in addition to the nursing and health care literature. Begin with a monthly list of key sources and scan the table of contents for each one. Then pick out those articles that will inform you and provide direction for you. Scan everything but read those few things that matter. Doing this enables you to learn to detect patterns that become the “next things” that you encounter.

Staying well informed is, I believe, a task of leadership. Harry Truman said it simply: “Not all readers are leaders, but all leaders are readers.” As you can note, I derive great learning from the thoughts and quotes of others. They help me to grasp complex concepts and to illustrate important lessons. I use quotes liberally as a teaching tool.

Second, always talk to the wise ones. And nursing is blessed with lots of wise ones. Seek out people who have experience, perspective, and ideas. Learn from those who have witnessed the cycles of life in and out of our profession. They have much to offer, and they share willingly. But never forget that wise ones may be found in every role and in every age category. Who hasn't been enthralled with the wisdom displayed by a young staff nurse as she talks about her patients and their needs and what she needs from you to make it happen? So always talk to the wise ones, wherever they may be.

In your skills as a great forecaster of the future, what would you suggest as the most essential skills in the next 10 years for chief nursing officers (CNOs) to acquire to be effective?

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This is an important one. My first reaction is that 10 years is much too long for anyone to envision with accuracy, given current realities. Let's look ahead over what will be important in the next 5 years. That's more knowable. I see three prime competencies for the successful contemporary nurse executive:

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#1 Competency: Quantification 

Beyond process to outcomes. I listed this one first simply because this is the one where the stakes are high and where we have much to learn. Nurse executives must acquire the ability to present crisp, key data points, not endless discussion. The skill must be developed to measure, to quantify, to compare, and to clearly identify clinical, financial, and operational outcomes. CNOs must become bilingual, knowing financial language as well as patient care language. That is the language that the contemporary organization understands and respects.

They must also learn to develop a detailed business plan that can become an institutional vehicle for strategic planning. That will give them a strong voice at the table, not simply a seat. See the difference? Resources are hotly competed for in every organization, and advanced business understanding by the nurse executive will be increasingly essential. That knowledge and skill moves them from using supplicant language to using executive language that is much more powerful and more likely to gain support for proposals that serve patients well. So the stakes are indeed high.

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#2 Competency: Deliberation 

I think of this one as “strategic thoughtfulness,” not concrete like quantification, but so important. Less structured, purely self-directed.

Deliberation is the ability to think, reason, listen, question, and analyze, debate, to read the extant literature, recognize the patterns. In many ways, the great Peter Drucker has been a personal and professional compass in the art of deliberation. His work guides our thinking. He asks what is right and what is ethical. What is the responsible thing to do? What is the future likely to be? How do I best deploy my organization's scarce and finite resources? What is our business? What should it be? How do we value and respect our human resources as the organization's prime asset? His writings answer many of these questions. To me, his work is a beacon for guiding strategic thoughtfulness, that essential and core task of leadership that is seldom discussed and often forgotten.

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#3 Competency: Communication, executive style 

There are many examples of the increasing demands for executive skills and behaviors of top-level executives and scrutiny of how you look, speak, write, and make presentations. Conducting yourself with integrity as a senior executive of the organization, effectively representing a major institutional constituency, is a necessity. Drucker would add to conduct yourself with good manners since they enable people to work together, even when they may not like each other. He wrote that manners lubricate an organization—beautifully said.

Another skill of executive-style communication is that of learning how to accurately read a room and then act accordingly. Focus on building your personal credibility by acquiring whatever executive skills are missing from your professional skill set. However, a caution: the carefully acquired skills that got you where you are today may not be the same skills needed as you go forward, so honest personal assessment is required. Always strive to achieve that desired state of communicating equanimity and imperturbability—not easy, but oh so reassuring to those around you.

And, most important, communicate the fact that values will always guide your leadership path. Principled leaders are consistently values driven. They make decisions carefully and within an ethical construct.

You are known for forming great working coalitions and relationships with many people and organizations throughout the United States and other countries. Was this purposeful on your part, or was it just part of your leadership style?

I believe it is an inherent part of leadership, and it is purposeful. Establishing partnerships, coalitions, and strong relationships is the essence of what all effective leaders must do. That's how meaningful work is accomplished. But you must first respect others, value what they know and what they can contribute, and ensure that these relationships will serve their purposes as well. This applies whether it is your own leadership team or an international coalition. The principles are the same.

Let's ask a question about your journey through nursing to the influential position you occupy today. Who influenced you? How did you become the leader we have come to love and trust?

So many wonderful influences, it's hard to acknowledge them all, but here are a few. My first teacher in a diploma program in nursing, Lucie Kelly, taught an 18-year-old about high standards, rigor, discipline, and excellence in performance—lessons that last. My first CEO in a small community hospital, who encouraged me to take the CNO role when I wanted to decline because I thought I wasn't ready, told me to learn to take advantage of opportunities when they present themselves, because when I was ready, the opportunity would likely be gone. That is one of those simple lifelong lessons I have passed on to others. (I took the advice and the job, and it was indeed the right thing to do.)

The nursing giant Rozella Schlotfeldt helped me see what leadership and vision really meant. The amazing Loretta Ford blends wisdom and determination with wonderful humor. Barbara Stevens Barnum, with her quick wit, deep intellect, and her friendship, first exposed me to the theoretical base of nurse executive practice. Frances Hesselbein, chairman of the Drucker Foundation, always makes herself available for counsel and is an incredible model of lifelong passion and contribution. Professor Marguerite Schaefer at the University of Pittsburgh first introduced me to the writings of Peter Drucker in graduate school. What a gift she gave! And of course, Peter Drucker himself, a guiding influence in my professional life for his sage writings and his clarity of thought. When he died last year at almost 95, he was still writing and pointing the way, sounding the clarion call for principled leadership.

Now that we know about who influenced you, tell us about your journey to the top. How did you come to have the career that you have now? Was it the result of careful planning?

I believe that many careers are serendipitous, not carefully planned, even though we may like to think otherwise. I know that mine has been serendipitous. A delight is never really knowing what is next but knowing that it will be challenging. Every position I have held has prepared me for the next one. My first CNO role was at Braddock General Hospital, a 200-bed community hospital in Pennsylvania. Other nurse executive roles followed, including a wonderful tenure as senior vice president for nursing at the Robert Wood Johnson University Hospital in New Jersey, serving jointly as clinical associate dean at Rutgers University School of Nursing. Then I served as vice president for nursing at Johns Hopkins Hospital, a stellar institution and a truly amazing experience, serving also as associate dean.

Now I am privileged to be at the Johns Hopkins University as professor in the School of Nursing, a school with a spectacular faculty and an unbelievably talented student body. Also, my career is now bifurcated, and part of my time is spent as executive advisor to the Nursing Executive Center of the Advisory Board Company in Washington DC., a program committed to providing best practices research and decision support to several thousand CNOs nationally. This is another new career model for me, but it all blends together well.

None of this was in a grand design. It all seemed to just happen. Each role seemed to lead to the next, and there is the opportunity to always apply all that you have learned. It has been a rewarding scenario and a privilege to have these exceptional experiences.

You have taken the role of mentor to the present and future generation very seriously throughout your career. Your work with the Johns Hopkins University School of Nursing, the Advisory Board Company's Nursing Executive Center, and the Robert Wood Johnson Foundation's Executive Nurse Fellows Program are testimony to your commitment. What is your advice to enable more people in the profession to take this work seriously?

Mentoring is indeed a professional responsibility. Most of us have been well mentored in our professional lives, and I believe that giving back is an expectation, a way to say “thank you” to those who have invested in you. I serve as senior consultant to the Robert Wood Johnson Executive Nurse Fellows program, and structured mentorship is integral to that program. The objective is to prepare exceptional nurses for national leadership through coaching and mentored experiences. It is an extraordinary program that models how leadership can be nurtured and developed and a fulfilling experience, as fellows then are expected to nurture others. It becomes a source of professional pride as you participate in the process.

What do you think is the greatest threat for the profession of nursing in the next 10 years? What would be your advice for the people who are making decisions that will affect that future now?

A serious question indeed. I am reminded of the words of General Eric K. Shinseki, former chief of staff for the armed services. He said, “If you do not like change, you will like irrelevance even less.” Therein lies the threat for nursing. If we do not create a new future for the profession, for health care, and for the work that we do, others will. And then we become irrelevant. A frightening scenario. We must as a profession equip ourselves to lead in what will predictably be extremely turbulent and challenging times.

When historians write the history of nursing 30 years out and they write about your contributions, what would you consider your greatest accomplishment?

Oh my. I have never envisioned myself in the history of nursing books. What I have tried to do, however, is to make a difference in the performance of nurse executives, specifically CNOs within care delivery systems. That is my passion. So much rests on the competency and performance of nurse executives. If they are not effective, patients lose. It is that serious. I always judged my own performance as a CNO in the following way: If it was not a good environment for the nurse at the bedside, then I was not successful. If the clinical nurse did not have the necessary systems, resources, and supports to care for patients at the bedside, I was not successful.

Another passion has been the nurse manager. Clearly, this is the most complex role in the entire organization. They are indeed the CEOs of multimillion-dollar clinical business units. This is a tough job, but an amazingly satisfying job, if we structure and support it well. Providing them with the necessary tools and skills to achieve and grow has been a long-time focus. This has been a worthy investment since their clinical business unit creates a satisfying environment for nurses, the desired outcomes for the patients they care for, and the business outcomes for their institution. They manage patient care, the direct work of the entire organization, an awesome responsibility. Nurse managers have my sincere affection and respect.

Here's that age old question about family and work: what would you like to share personally about how you have been able to balance work and family?

Aha, that ubiquitous search for balance. We always think someone else does it better than we do, but they really don't. Every busy person struggles with this. There are times we do it well, and other times we do it poorly. I have had the gift of a wonderfully supportive family to make it easier to meet all the demands of a busy professional life. I am deeply grateful to them.

Also, over time I have become more aware of some fundamentals such as the fact that people look to leaders to replenish their energy, but you cannot do that for others unless you first replenish your own. That takes a structured plan for serious self-care, your personal lifeline when you have a high pressure job. Another reality: Lily Tomlin's words on the concept of sequencing. She says you can have it all, you just can't have it all at once. So true. Some things just have to wait.

Another common sense comment I always remember are the words of a physician colleague who said, “There is an unstoppable stream of work. The only decision one can make is when to interrupt the stream.” Important lesson there. It puts work in perspective. Planned interruption of our endless stream of work is both necessary and healthy, especially in our 24-hour, always wired environment.

A refreshing perspective on balance came in an article in the magazine Fast Company by Hammonds entitled “Balance is Bunk.”¹ How could you not read an article with that title? It was liberating in that the author notes that we are constantly urged to pursue perfect balance in our lives, but that is an unattainable illusion. She observes that life is an ever changing portfolio of responsibilities and activities, and we are required to constantly adapt to those changes. So the reader is encouraged to simply answer the question: Are you happy? If the answer is yes, you are in balance. That is so reassuring, and reading that balance really is bunk, as Hammonds says, can help you feel better about yourself and how you are managing your hectic but fulfilling life. A great common sense lesson for nurse leaders everywhere.

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Reference 

1. Hammonds KH . Balance is bunk. Fast Company 2004 Oct:68-76 . Available at: http://www.fastcompany.com/magazine/87/balance-1.html Accessed May 3, 2006
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