Abstract
In the 1800s, Florence Nightingale encouragingly suggested that one must never lose an opportunity to urge a practical beginning. Never knowing exactly which one and where, these small practical beginnings often lead to self-germinating and rooting, in a similar vein to that of a mustard seed. This article illuminates the unanticipated career influence of one nurse’s planted seeds and practical beginnings on her young, severely injured, patient. The article takes the reader on an unexpected, somewhat unconventional nurse leader journey, and provides enduring, replicable practice, and leadership lessons, learned along the way.
Key Points
- •There is no question that the last few years of global pandemic nursing have propelled the profession into a new, somewhat unpredictable, practice landscape. For leaders, there are a number of practical, managerial, applications that stand the test of challenging times.
- •Throughout one’s life and career, there are many opportunities to shape, shift, and strengthen those around us, be it patients, staff, loved ones, or any other number of stakeholders. Strong, resilient leaders, build these opportunities into their life’s work.
- •Nursing leaders are uniquely positioned (and trusted) to bring and keep evidence-based practice approaches on the front burner no what matter is happening around them. Mentorship, retention strategies, health and wellness approaches, active listening, and emotional intelligence, are further explored as key pillars through one nurse leader’s journey.
“So never lose an opportunity of urging a practical beginning, however small, for it is wonderful how often in such matters the mustard-seed germinates and roots itself.”
(Florence Nightingale)This is a bifurcated history of an inimitable and somewhat unexpected nurse leader journey incorporating beneficial leadership lessons learned along the way. Two fateful days before Christmas 1971, an energetic 6-year-old made her way to a local sledding slope known locally as “suicide hill.” While the child’s mom, relatives, and friends were busy baking holiday cookies back home, the adventurous 6-year-old was anxious to speed down the freshly snow-covered steep incline. After swiftly pushing away with a running start, the girl and 4 friends jumped into their makeshift plastic toboggan heading rapidly down the frozen hill.
The Accident
The front passenger suddenly yelled “pole,” followed by “all bail.” The youngest passenger instead decided to extend her left leg to slow the toboggan’s velocity. The red piece of plastic suddenly smashed into a metal pole with an audible thud and came to a halt. The young girl, attempting to lead the sledders to safety, was left staring at a mangled leg, bones visibly protruding, with indescribable pain at the slightest of micro-movements. Word of the accident quickly spread. Instead of waiting for an ambulance, the girl was hoisted up, in the toboggan, to her mom’s waiting station wagon. Every subsequent bump, en route to Kansas City, Missouri’s Medical Center, produced loud shrills from the now excruciating head-to-toe pain.
Triage
Upon hospital arrival, hundreds of people (or so it seemed) surrounded the girl, lifting her off the red plastic and onto a medal bed on wheels. The physician, Howard J. Ellfeldt, MD, arrived and introduced himself. The young girl recalled him giving everyone orders on what to do next, and that her football enthusiast father was pleased when meeting the doctor. (Dr. Ellfeldt was the main physician for the Kansas City Chiefs football team, and a local celebrity of sorts).
The next person the adolescent recalled meeting was a lady dressed in all white, white dress, white shoes, white hose, and a white pointy hat on her head. The lady in white, also giving instructions to multiple people, kneeled, and took her patient’s hand. She softly told the patient she was the head nurse and would be with her throughout her time in the hospital. The patient was both comforted and confused by this interaction as the nurse’s name tag said Doctor, RN.
Turned out her name was, in fact, Nurse Doctor.
Surgery/Admission
While Nurse Doctor rolled her patient down the hall to what would be the operating suite, she never let go of her patient’s hand. In this extremely bright room, the last thing the patient recalled was RN Doctor organizing “hundreds of things” before Dr. Ellfeldt came in wearing a green outfit with rubber gloves on his uplifted hands. The next memory was that of painfully “coming to” on what was now Christmas Eve, in a stark white hospital room reeking of sour pickles (melamin formaldehyde from the cast). Thus began child’s yearlong repair and recovery journey.
The patient, now enclosed in a head to toe, white plaster of Paris body cast, suddenly realized she could not move. This frightening discovery triggered the 6-year-old to panic and rebel. She started orchestrating activities that included peeling off cast pieces, upper body swinging from the traction bar, trying (unsuccessfully) to lower the hoisted-up leg, finagling bed pan placement so contents would end up in the bed, missing the hard, pink, plastic container. She refused a smelly antiseptic hospital soap sponge bath by knocking the water onto the shiny floor. The shiny floor is also where the food left for her on a plastic tray landed as well.
The Nurse Leader Returns
Hearing of the chaos, Nurse Doctor soon arrived, injections in hand. After much yelling and screaming from her patient, Nurse Doctor pulled up a chair, while asking if she could sit down, She sat closely next to the bed, softly explaining the process for healing (and eventually going home). She then, ever so gently, inserted a series of shots that were barely felt, confirming that she would continue to be this patient’s nurse. Day to day, in her starched white dress, white hose, shoes, and white, triangle-shaped cap, Mrs. Doctor, RN, comfortingly explained that the nurse and her patient were in this together. Her exits from the bedside were always preceded by a firm handshake.
Nightmares
None-the-less, the memories of a hectic emergency room, her cut-up snow suit, protruding bones, what seemed like 100 x-rays combined with someone coming in her room every hour shining a flashlight, left the child with nightmares and insufficient sleep. Life-sized gifted stuffed animals—a giraffe, a dog, and smiling Mickey Mouse—all seemed to come alive at night, triggering escalating fright and nonstop call bell pushes. Bed bound and confined in a movement-restrictive hard white plaster shell, new roommates incessantly screaming or snoring, and food that looked like one thing yet tasted like another, called for an escape plan from the confines of this nightmare. Sadly, she quickly learned, there was to be no such conceivable plan. Her only real comfort came from Nurse Doctor’s visits. She sometimes brought hospital ice cream, stayed into the night, telling jokes, and updating her patient on her progress. On days she was not there, Nurse Doctor would place a phone call to her patient, always anxiously awaiting to speak with her on the other end.
Career Shift
After what felt like years, but was just 1, the patient was cut loose with a saw. Despite most of the patient’s family members working in health care, and Nurse Doctor’s comfort, this patient firmly believed that any thought of working in a hospital herself, or being a doctor or nurse, would be impossible. Carrying on the family’s health care legacy seemed to be out of the question. The lengthy, bed-ridden, hospitalization shed light on her understanding of what nurses and doctors do. Yet, unlike many of her peers, who wanted to be a doctor or nurse when they grew up, a future career helping sick people in a hospital seemed completely out of the question. Her plan was never to return to the Kansas City Medical Center, or any hospital for that matter.
Coincidentally, as time rolled on, a weak stomach, selective eating, and fear of blood were commonplace with this accident-prone youngster. Blood-baring injuries and bone breaks were frequent. These included tripping over a dog running at full speed, on fresh gravel, busting open both lips, a nose break, and kneecaps gushing with blood full of embedded gravel stones leaving permanent patella scars. Body bruises were ever-present from many unsuccessful attempts at learning to ride a horse, broken fingers and wrists from the softball league, muscular strains, and injuries from over exertion on state ranked tennis and swimming teams, and a frequently bleeding nose eventually requiring cauterization. All hospital and doctor’s office visits were filled with fear of staying there overnight, coupled with tears, screaming, and long bouts of refusal to speak to anyone.
College/Hotel Leadership
As a young, college-bound woman, a dually focused, undergraduate degree in communications and political sciences was a first step towards her adult career choice. While getting a degree and working part-time, she was promoted to a 24/7 on-call lead front desk employee at a highly rated hotel. The hotel’s president, impressed with the positive, generous, customer feedback received from guests, promoted the new college graduate to her first full-time job, director of catering, at a 5-star hotel. A leadership career in hospitality including sales, marketing, public relations, and customer service quickly followed. Minus an occasional overbooking, the youthful hotel executive often reflected on how “heads in beds,” as the industry called it, was much less fraught with anxiety, fear, and trauma than laying a head in a hospital bed.
Global travel leadership duties evolved, serving as inspiration for pursuing a London-based MBA, and working in the UK with Sir Rocco Forte’s hotel conglomerate. Upon return to New York City (NYC), the young lady, now a recognized hospitality-industry leader, was recruited by a fortune 500 company to specialize in developing international travel and leisure market sectors. The pressures of a high-profile, quota-based, Fortune 500 marketing leadership position led to a mental health respite and a move from NYC. A slower paced, scuba-diving life awaited her in Cozumel Island, Mexico (an island made famous for scuba diving by Jacques Cousteau). After obtaining dive master certification and consulting with the island’s largest scuba diving company (coincidentally run by a retired chief nursing officer named Apple Applegate), it was once again time to return to NYC. Ironically, there had been a hyperbaric chamber emergency hospitalization in Cozumel requiring intervention by RN Apple. The take-aways from this island health scare were that eating too many habanero peppers puts the body into toxic shock (resolved with alkaline injections), and impressively, and impressionably, once a nurse always a nurse. It had been over 20 years since retired CNO Apple Applegate had worked in a hospital, yet she knew exactly what to do for her pained employee patient in “habanero pepper body shock.”
Health Care Leadership
Post-911’s aftermath, an enticing NYC, hospital-based, patient centered care specialist (patient advocate) opportunity surfaced. The position oversaw 5 large emergency departments (treating over 300,000 patients a year). Hospitals were newly striving to instill better customer service in a similar vein to that of the hospitality industry. Thus, hotel industry leadership experience was an asset as the position required frequent and rewarding patient and staff interactions through the lens of a patient or loved one. Simultaneously, friends, patients, peers, hospital leaders, parents, and physicians encouraged reconsideration of a career in nursing. Most importantly, perhaps, was an emergency department (ED) nurse leader mentor taking the patient advocate administrator under her wing.
Nurse leader mentorship coupled with hypnosis taught by the administrator’s father physician, helped diminish the fright of retraumatization from being around the infirm. Somewhat surprisingly, as Florence Nightingale once suggested was possible, a practical beginning enabled the mustard seed to germinate and root. A third career, new nursing journey commenced. Working full-time, financially supported by the hospital, nursing school commenced. After part-time, night, and weekend nursing studies, clinicals, and RN licensure, an ED Level-1 trauma center nurse fellowship was offered. As a trauma nurse working with acute exacerbations of medical and psychiatric conditions, complex comorbidity patients became this new nurse’s passion. In addition to life-threatening traumas, a significant amount of time was spent, with support from seasoned nurse mentors, on the complex care needs of comorbid psychiatric and medical conditions.
This new nurse recognized a need, not only for mentorship throughout her journey, but also for nurses trained in, and comfortable with, simultaneous care of both medical and psychiatric ailments. Advanced, continuing education and training also became a priority. A second master’s degree, an MSN, now in hand, the next nursing position offered was in leadership as the patient care director (with an overlapping stint covering director of nursing and quality in psychiatry) of a unit specializing in psychiatric and medical comorbidities. In the latest, post-doctorate move, the nurse leader now serves as the chief nursing officer at a prestigious psychiatric research institute in upper Manhattan. She holds adjunct professorship positions at 2 renowned schools of nursing, teaches, mentors, and frequently volunteers in the community, promoting the nursing profession and its endless possibilities. Leadership (and peer) mentors, and advanced education played critical roles in encouraging this current move. Eleven years have swiftly passed since this nurse leader’s first 12-hour ED shift as a new nurse resident. She remains committed to evidence-based patient care, local and global advancement of nursing professional practice, and promoting the importance of mentorship every step of the way.
Bedside Nurse to Nursing Leadership Lessons Learned
Providing the appropriate toolbox to meet the ever-increasing, morphing, practice needs of nurse leaders, nursing staff, and patients remains of paramount importance, especially given these tumultuous times. As has been shown time and again, improving career commitment, retention, engagement, and well-being requires suitable, specific, flexible tools and training. Even more crucial as the profession explores new, somewhat unpredictable, nurse and nurse leader global pandemic-scarred landscapes, layered on top of previously challenged professional landscapes.
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Although lessons are still being learned, in a somewhat rapid advance through the proverbial nursing career ladder, several pearls of wisdom are highlighted as key take-aways.Chapter 3: Workforce of the Future. In: Nursing, Transforming Healthcare.
https://nursing.jnj.com/anth-workforce-of-the-future
Date accessed: October 21, 2022
Mentorship for Professional Practice Recruitment, Retention, and Advancement
Throughout this nurse leader’s career path, the power of mentorship cannot be overstated. Both inside and outside of nursing, especially at difficult career intersections, the mentor can serve as a guide. Most notably, in this nurse leader’s journey, the simple act of shadowing both managerial leaders and bedside nurses, sharing experiences, and patient stories coupled with mentor support, inspired enrollment in exploratory nursing courses. Might others be waiting for someone to let them “lean in” to the nursing world in a similar fashion? The ongoing trust bestowed on nurses positions the profession to better mentor, attract, and recruit than is currently happening. Students, volunteers, new graduates, and imperatively, non-nursing colleagues, may discover the nursing profession via a mentorship, bringing unique, worldly experiences with them. Once on an identified career path, research confirms the value and importance of ongoing mentor/mentee programs for students through senior, “C-suite” leaders. In a groundbreaking 2015 Harvard Business Review study “CEOs Need Mentors Too,” de Janasz and Peiperl’s years of research confirmed the positive, personal, and professional value of continual, lifelong mentorship.
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,- de Janasz S.
- Peiperl M.
CEOs Need Mentors Too. April 2015. Harvard Business Review.
https://hbr.org/2015/04/ceos-need-mentors-too
Date accessed: October 21, 2022
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Efficacious mentor/mentee relationships may help strengthen or sustain one’s personal and professional path. Mentors, often more seasoned professionally, and politically, help instill confidence, provide expanded mentee networking opportunities, career track advice, support, and personal and professional skill building, including emotional intelligence. Strong mentors can provide clarity on the value of well-being, the learning and resilience-building opportunities from mistakes, missteps, and perhaps even a probation or termination. COVID introduced an additional advantage of improved technological communications. Mentorships can now be established and maintained virtually, transcending geographical, workplace, and health care–specific boundaries. Importantly, mentors can also emphasize the value and efficiency of exploring advanced nursing education and training via technological platforms. This approach is shown to enhance retention, and equitable, patient-centered, approaches to care delivery.
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- Wolters Kluwer
Mentoring across the nursing profession: lessons from the ANA.
https://www.wolterskluwer.com/en/expert-insights/mentoring-across-nursing-profession
Date accessed: October 21, 2022
Value of Advanced Education and Training for Retention and Equitable Care Delivery
As this nurse leader also learned, ongoing training, education, and professional development strengthen the impetus for exploring and expanding career growth, Education helps instill confidence, reduce errors. and prepare new and future nurses for managerial positions. In this leader’s case, cross-training in medical, psychiatric, end-of-life expertise, all facets of mental illness, coupled with value-based learning and leadership skills contributed to a unique skillset. Studies show that advanced education and training strengthen nurses’ professional practice, and practice transitions, while building confidence and promoting retention. In the “Future of Nursing Report: 2020-2030,” the National Academy of Medicine (NAM) emphasizes that throughout the coming decade, it will be essential for nursing education to evolve rapidly, preparing nurses to meet many rapidly evolving challenges. These include social determinants of health, population health improvements, and health equity promotion.
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Populations are aging, diversifying, and sadly, declining in mental and physical health to name but a few challenges facing 24/7 nursing care.National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. 7. Educating nurses for the future. In: The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: National Academies Press; 2021.
Recruiting, teaching, and establishing diversity from students to faculty is imperative for establishing a workforce more closely resembling populations served. Patients and teams benefit from skilled, culturally competent, clinician-delivered evidence-based practice. Clinicians are also beneficiaries of culturally competent care knowing their work with diverse populations is supported by the latest professional ethnic and cultural practices. Nurses have come to expect continued educational support throughout their careers, and when not supported, the consequences can be detrimental. Studies have shown that nurses across all points of their career path, identify continued professional development, cultural competency training, and support as part of a heathy workplace.
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Creating Healthy and Psychologically Safe Workspaces
Budget-Neutral, Evidence-Based Simple Acts
A first, and lasting, memory of encountering, and working with, a nurse leader as a traumatized 6-year-old patient, was that she took the time to explain what was happening step by step. She used age-appropriate language while holding her small patient’s hand with bent knees or sitting down to meet a youngster at eye level. Then, conscientiously stood up to liaise with distraught family and friends.
No matter what role one plays in the nursing profession, what it feels like to be the patient, and/or their loved one, must not be forgotten. Simple acts of kindness, a warm blanket, fresh pillow, and sitting down, impact perceptions of patient care. Studies have shown that the kinder the provider seemed to their patient, the more time the patient felt was spent on them. A provider’s warmth can affect how much a patient responds to their medical treatment. Additional studies have long shown that the simple act of sitting down with a patient increases their perception of time spent and care given.
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Might this approach also work with members of our own teams? The tendency to hastily rush through a workspace, often in a suit, and on foot may be positively altered by taking a seat next to the employee and practicing active listening.Active Listening
Many have heard of the Pareto Principle, also called the 80/20 rule, the law of the vital few, or the principle of factor sparsity. Simply put, it says that for many events, roughly 80% of the effects comes from 20% of the causes, or 20% of inputs generate 80% of outputs. It's a very simple concept, but many people struggle to use it. When it comes to communication, the practical application of the 80/20 rule is to actively listen 80% of the time.
The application of the Pareto analysis in management allows managers to focus on those items that have the most impact on their desired outcomes. Interestingly, the result from a recent Pareto principle analysis of virtual team communications showed that lack of trust and misunderstanding were the 20% of causes creating 80% of a virtual team’s communication problems providing the team with the 2 areas to fix for better productivity. If we are going to listen most of the time, we ought to do it well and that means using active listening. It is the most effective form of listening, and it’s also the most challenging to use. Understanding and practicing listening actively, takes effort, especially when first mastering the skill. However, numerous studies support the results of using a Pareto approach to individual and team communications.
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- Sanchez J.
Pareto Principle – 80/20 Rule. 2019. FP&A Trends website.
https://fpa-trends.com/article/pareto-principle-8020-rule#:~:text=When%20it%20comes%20to%20communication
Date accessed: October 21, 2022
Instilling Emotional Intelligence and Psychological Safety
Open communication, psychologically safe, trusted workplaces have been shown to foster active emotional exchanges. Open, safe, spaces can enhance emotional intelligence and a congruence of values and emotions between leaders and team members. Emotionally intelligent nurse leaders can role model simultaneous contributions of emotional intelligence when working with staff and patients. Meeting staff, and patient needs, can enhance organizational performance, and result in a healthier workplace.
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Conversely, if left unchecked, emotions and values may remain incongruent, decreasing job satisfaction and engagement, contributing to burnout. A leader’s emotional intelligence has been shown to have a direct impact on employee job satisfaction. High levels of emotional and value-based leader-staff congruence fosters job satisfaction, and one may argue, subsequent patient outcomes.16
Frequent “Pulse Check” Barometers on Staff and Patients
Leading during ongoing tumultuous times of pandemics, evolving viruses, national and global conflicts, fluctuating workforce and patient needs, including increasing levels of health decline, requires interventions that help uplift people. Positive relations supporting one’s purpose are invaluable, human connection has been shown to provide the greatest sense of purpose. Leaders hold an immense responsibility to instill this sense of connection, belonging, and inclusion to all their stakeholders. One evidence-based approach to this may include a proven practice of brief intentional rounds. Frequent, minutes-long, intentional “pulse checks” held before starting a meeting, or on unit staff and patient rounds, have been shown to encourage and boost emotional well-being. Suggested questions include asking for a word or phrase that describes how someone is “showing up” today,” and how someone is “really, really, feeling.” Psychologically safe space creation encouraging shared feelings may support and encourage others to recognize that they are not alone in thoughts and feelings. Opening up to others in a safe space, enhances caring, purposeful connections. Leaders with this ability continually remind staff, and patients, we are all connected.
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A 3-Minute Microdosed Breathing Space
Recent and ongoing studies of a minutes-long, microdose of mindful breathing (3-minute microdosed breathing space [3MBS]), have shown resoundingly positive results. Both pre-COVID and during, nurses, including acute care, psychiatric, oncology, and emergency, nurse leaders, doctoral students, and chronically ill patients have benefited in areas of burnout, compassion fatigue, resilience, stress, and quality of life by purposefully breathing a few times per day. Supporting and making space for the brief, simple, 3MBS exercise, available freely via YouTube, hospitals and units have begun embracing this practice at change of shift, and on breaks, in both group and individual practice for nurse and patient health and well-being.
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In preparing new generations of nurses for critical leadership roles ahead, it is essential for nurse managers to continue honing their own skills in this “new normal” and unpredictable landscape. This nurse leader’s bone-shattered, years-long, patient recovery experience with Nurse Doctor feels like lifetimes ago. However, the memories and influence of this resonant, emotionally intelligent, nurse leader bestowed on her traumatized 6-year-old patient have never been forgotten. Nurse Doctor’s simple, caring, kind acts with her patient, sitting down, creating a psychologically safe space, actively listening with consistent check ins, was indeed the unexpected practical start of a mustard seed germinating and rooting itself, as Florence Nightingale suggested it could be.
References
- Chapter 3: Workforce of the Future. In: Nursing, Transforming Healthcare.(Available at:)https://nursing.jnj.com/anth-workforce-of-the-futureDate accessed: October 21, 2022
- CEOs Need Mentors Too. April 2015. Harvard Business Review.(Available at:)https://hbr.org/2015/04/ceos-need-mentors-tooDate accessed: October 21, 2022
- The mentorship experience of students and nurses in pre-registration nursing education: a thematic synthesis of qualitative studies.Nurs Health Sci. 2021; 23: 69-86
- The value of nurse mentoring relationships: lessons learnt from a work-based resilience enhancement programme for nurses working in the forensic setting.Int J Ment Health Nurs. 2020; 29: 992-1001
- Mentoring the working nurse: a scoping review.Hum Resour Health. 2020; 18: 52
- Mentoring across the nursing profession: lessons from the ANA.(Available at:)https://www.wolterskluwer.com/en/expert-insights/mentoring-across-nursing-professionDate accessed: October 21, 2022
National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. 7. Educating nurses for the future. In: The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: National Academies Press; 2021.
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- When your doctor “gets it” and “gets you”: the critical role of competence and warmth in the patient-provider interaction.Front Psychiatry. 2019; 10: 475
- Effect of sitting vs. standing on perception of provider time at bedside: a pilot study.Patient Educ Couns. 2012; 86: 166-171
- Patient-centeredness and the Pareto principle: getting at the matter of what matters to our patients.Nephrol Dial Transplant. 2020; 35: 1647-1648
- Strategies to improve communication management within virtual project teams.Pertanika J Sci Technol. 2019; 27: 2015-2030
- Pareto Principle – 80/20 Rule. 2019. FP&A Trends website.(Available at:)https://fpa-trends.com/article/pareto-principle-8020-rule#:~:text=When%20it%20comes%20to%20communicationDate accessed: October 21, 2022
- Effects of nurses’ emotional intelligence on their organizational citizenship behavior, with mediating effects of leader trust and value congruence.Japan J Nurs Sci. 2018; 15: 363-374
- Emotional intelligence congruence: the influence of leader and follower emotional abilities on job satisfaction.Leadersh Organ Dev J. 2022; 43: 788-801
- Intentional rounding – an integrative literature review.J Adv Nurs. 2018; 75: 1151-1161
- Nurse leader cultivation of rituals: providing a sense of community and connection.Nurse Leader. 2022; 20: 340-343
- Compassion fatigue in oncology nurses in Turkey.Holist Nurs Pract. 2022; 36: 304-310
- An exploratory study of a 3-minute mindfulness intervention on compassion fatigue in nurses.Holist Nurs Pract. 2020; 34: 274-281
- I get by with a little help from my peers: mindfulness and peer support for doctor of nursing practice students.Nurs Educ Perspect. 2022; 43: 312-314
Biography
Rebecca A. Owens, DNP, MBA, MSN, RN, PMH-BC, is the Chief Nursing Officer at the New York State Psychiatric Institute in New York, New York, and nursing faculty at Columbia University School of Nursing, and Case Western Reserve University, Frances Payne Bolton School of Nursing. She can be reached at [email protected]
Article info
Publication history
Published online: December 01, 2022
Accepted:
November 1,
2022
Received:
October 22,
2022
Identification
Copyright
2022 by Elsevier Inc. All rights reserved.
