Management and leadership at the bedside

It's not the medicine we give, but the hand that gives the medicine. (Kobina Esia Donkah) Professor Donkah is a cultural medical anthropologist from the University of Cape Coast, Ghana. His powerful teachings of culture and understanding remind us all that the ‘what’ of our actions is preceded in importance by the ‘who and how’. Through the empirics and aesthetics of our approach to beside care – the inner leader qualities that are informed by scientific knowledge, confidence, communicative and relational style, we are reminded that the medicine we give pales in priority to ‘how’ we deliver it. Those inner leader qualities are the hallmark of beside excellence and patient safety. They also contribute the unique nurse artist in all of us. Nurse leaders are the heart and soul of health systems change. The Institute of Medicine's (2010) Future of Nursing Report suggests four strategies for successful change to be realized that include: (1) nurses should practice to the full extent of their education and training, (2) nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression, (3) nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States, and (4) effective workforce planning and policy making require better data collection and information infrastructure. While clinical nurse leaders, clinical nurse specialists and doctoral prepared nurse leaders offer systems leadership informed by educational achievement to manage, lead and mentor change, we should never underestimate the inner leader of the bedside nurse that models and empowers change through their ‘Ways of Knowing’ and bringing personal, empirical, aesthetic, ethical knowledge and understanding to their individual practice and team collaboration exchanges. Wieck et al. (2002) contend that empowerment is an essential quality inherent in effective leaders in all capacities. Empowerment fills novice nurses with confidence and confidence leads to self efficacy and satisfaction. As the profession prepares for workforce issues of predictive shortage and redistribution, while continuing to recruit our best and brightest into academic programs we must pause to maintain linkages between academia, health care systems and the bedside. Passionate clinicians lead to healthy systems and moreover to optimal patient outcomes. Effective communication has long been established as foundational to interpersonal, peer, nurse-patient, interprofessional and also systems level operations function. Effective communication occurs through exchange verbally, non-verbally and encompasses characteristics that include portrayal of health and illness state and culture. All these add to the complexity and appreciation of the individual skill and patience required for effective communication. Hence, effective communication is a leadership viewpoint and wisdom, predicated on thoughtfulness, teamwork and value for others' perceptions. The articles included in this issue under the domain of communication include (1) fostering change among nurses (Portoghese and colleagues, pp. 582–591), (2) establishing patient handoff quality through teamwork and trust (Clarke and colleagues, pp. 592–598) and (3) addressing lateral violence to promote communication (Ceravolo and colleagues, pp. 599–606). They all present new knowledge and compelling insight toward better understanding and guiding future communication work that is a salient component to systems' functioning and health care outcomes. As expert nurses develop skills and understanding of patient care over time through a sound educational base as well as a multitude of learning experiences, (Benner 1984) the transition from novice to advanced beginner, to competent, proficient and expert occurs. With this transition we are reminded of our humility of returning to less competent levels when we ‘spread our wings’ to make practice setting changes that are important to us personally and professionally. Hence, confidence is never quite fully achieved, but is a dynamic process we should always honour. This issue explores two articles examining confidence from the vantage points of individual nurse's self-assessment of perceived competence (O'Leary, pp. 607–614) and transition support program for newly licensed nurses that support confidence, leadership development and enhance retention (Dyess & Parker, pp. 615–623). It is possible to claim that there is a paradigm shift that is focusing on evidence-based practice (EBP) through the evolution of undergraduate education. Novice nurses today receive contemporary education regarding EBP and more experienced nurses are more commonly the beneficiaries of hospital systems providing education and training for the adoption of EBP. The benefits of this growing awareness are three fold as we think about the EBP framework: (1) best available evidence is increasingly used in practice and in different types of (special) populations; (2) clinician expertise is strengthened; and (3) value for patient preferences is acknowledged. Nurse leaders and nurses ‘talk the talk’ and have authentically begun to ‘walk the walk’ of EBP, convincingly as more and more systems embrace excellence in nursing care. This issue includes original research articles that explore and report nurse and nurse leaders varied interfaces across populations and domains of practice that include family centred care in paediatrics (Roets and colleagues, pp. 624–630), patients who struggle with eating disorder (Rørtveit and Severinsson, pp. 631–639), cognitively impaired elders (Nilsson and colleagues, pp. 640–647), and infection prevention and control (Ward, pp. 648–658). Attitudes, leadership qualities and adoption of evidence-based practices represent the efforts to illuminate the issues and adoption strategies to improve quality at the bedside. The issue of turnover represents an important area of research as systems attempt to maintain fiscal control in a turbulent health care industry. Turnover is one area where costs to systems have grown exponentially. For example, in 2002, a national survey in the United States conducted by the HSM Group, Ltd. (2002) determined that the cost of orienting a new nurse exceeded $145,000 while turnover of those new nurses was >21%. Today these costs are even higher. In a study conducted by Spivak et al. (2011) expert clinical nurses across a multitude of care settings relied on leadership for guidance related to work behaviours and for best employment choices. The articles included in this issue build on this very idea. Additionally, the reports from different countries span a range of topics from exploring early resignation of Japanese novice nurses (Niitsuma and colleagues, pp. 659–667) to turnover, satisfaction and/or burnout among groups of Saudi nurses (AbuAlrub & Alghamdi, pp. 668–678) and South African critical care nurses and nurse leaders (Klopper and colleagues, pp. 685–695). Also included are care setting specific papers regarding turnover among behavioural mental health nurses in the USA (Smith and colleagues, pp. 679–684) and predictors of retention in emergency nursing in Canada (Sawatzky and Enns, pp. 696–707). These articles suggest that such workforce concerns as retention and turnover are a major challenge in many countries and that aspects related to turnover are contemporary and complex issues in nature. The attempts to describe and study this phenomenon as well as offer intervention strategies for change and control are not easy topics and thus the research community still has work to do. There is a critical interface among the themes described in this editorial and the articles included in the issue. Effective communication is the most important foundation that informs a health care system, so that it is possible to offer high quality nursing care. Additionally, confidence among nurses and leaders and the importance of addressing confidence and competence in nursing practice informs attitudes and staff satisfaction. The articles of this issue contribute new knowledge to these themes through theory development, research and improvement science as a growing body of evidence targeted at clinical bedside leadership. Most importantly, this issue reinforces, through vast international scholarship from the nurses, leaders, managers, educators and researchers at the bedside, that our vision should be to advance evidence-based nursing practice that aims to improve patient and population outcomes, strengthen health systems and the profession of nursing. The editors would like to thank all of the authors of this issue for sharing their inner leader through research and scholarship.

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