A reinvention of the American hospital system seems imminent once again. Unrelenting, and now pan-professional, workforce shortages are creating new demands for a different approach to hospital work. 1,2 The hospital chief nursing officer (CNO) is positioned to contribute to the quality of solutions in one's organization through credible leadership and by configuring work environments that achieve optimal outcomes for patients and nurses. As organizational policy maker, the CNO often is directly involved in planning and influencing the strategies related to the hospital workforce and environment, patient care advocacy, technology, and patient safety. Integrating the challenges of healthcare reconstruction into decisive action is enhanced by a continuous flow of relevant administrative research with practical implications.

The American Organization of Nurse Executives (AONE), a professional organization of nurse leaders, supports administrative research in several ways. The Journal of Nursing Administration (JONA) and AONE collaborate to publish annually an important research issue devoted to nursing administration topics. This research issue appears on the reading list of many CNOs.

The articles selected for publication in the administrative research issue were evaluated using the AONE's 2001-2002 research priorities (see the masthead for AONE's 2003 priorities). These research priorities build on previous experience, current knowledge, and belief in the future of nursing leadership and healthcare. The priorities are focused, timely, and comprehensive. Also, they are aligned well with AHA's agenda involving workforce, quality, and patient safety. Four areas of concern frame AONE's priorities:

* Work environment and workforce;

* Patient care advocacy;

* Technology; and

* Patient safety.

Work Environment and Workforce

AONE believes that work environment and workforce issues are incredibly significant because of their implications to a variety of stakeholders: patients, the public, educators, researchers, employers, and policy makers. The healthcare work-force must consist of knowledge workers who are available and competent to provide care, who can promote positive work environments, and who can lead future patient care delivery systems. Workforce and work environment issues are multi-variable and continue to grow in complexity. These unresolved issues create a looming crisis for hospitals. Recently, two reports were published 1,2 that promulgate the thinking that strong leadership and aggressive action are needed to address the nursing shortage, build a thriving workforce, and avoid a crisis in healthcare. Strong decisive leadership is supported with actionable data from relevant research studies. Ten areas (with specific areas of concentration) comprise AONE's work environment and workforce research agenda:

* Accountability (credentialing, regulation);

* Composition (educational preparation, experience, specialization, independent practice, role/function, skill level, skill mix, generational diversity);

* Distribution (care settings, urban/ rural, regional, virtual, multi-state licensure compact);

* Diversity (age, gender, and ethnicity.

* Leadership development at all levels (from executive to clinical at point of care, succession planning, and mentoring);

* Nurse staffing (relationship to improving patient outcomes);

* Professional growth (new and expanded competencies, knowledge workers, continuous learning, culturally competent care);

* Recruitment (nurse image, collaboration with nurse education);

* Safety (hazardous exposure, workplace violence, ergonomics); and

* Work environment and retention (care models, compensation, recognition models, collaboration, autonomy).

Patient Care Advocacy

Nurses increasingly are accountable for healthcare that is grounded in a social contract with the public that nursing serves. Most nurse leaders recognize the importance of the patient care experience and remain accountable for quality patient care delivery, systems, and nursing practices. AONE believes that nursing staff, as patient advocates, must aggressively seek to understand healthcare relationships and accountability, resource utilization, patient safety, and outcomes measurement and analysis. Strong decisive leadership on patient advocacy issues depends on a solid research foundation. Five areas (with specific areas of concentration) make up the AONE patient care advocacy research agenda:

* Accountability (continued improvement in healthcare processes and outcomes across the continuum);

* Effective use of resources (new management methods and techniques, appropriate resource allocation);

* Ethics (patient rights, end-of-life issues, business, ethics, compliance);

* Development and use of new knowledge (evidenced-based practice models, measurement and analysis of patient outcomes); and

* Relationships (interactions with and connections within the community, among healthcare professionals and within healthcare settings, insurers/third party payers, regulatory agendas).

Technology

Technology enhances the way nurses learn and provide care. Nurse leaders are accountable for guiding adaptation and implementation of technological changes. AONE believes that outcomes of advanced technology use include the healing and compassion components of care. Strong decisive leadership in the complex area of technology requires relevant research. Seven areas (with specific areas of concentration) make up the AONE technology research agenda:

* Electronic patient record (design, implementation, and evaluation, standardized nursing language);

* Internet use (impact to consumers and the nursing profession, access to quality data, providing Web-based learning strategies);

* Managing technological change (technology system design, implementation, and evaluation);

* Outcomes (technology deployment and impact to care processes);

* Patient confidentiality (impact of regulation);

* Systems improvement and infrastructure changes (accommodation of new technology); and

* Utilization of information technology (impact of technology on learning of health professionals and for education of patients and families).

Patient Safety

Nurses are accountable for safe practice and for working collaboratively with all members of the healthcare team to reduce risk and to minimize errors. A solid program of research studies regarding patient safety provides a blueprint for CNO actions. Four areas (with specific areas of concentration) comprise AONE's research agenda for patient safety:

* Adverse occurrences sensitive to nursing (assessment and interventions to prevent falls and skin breakdown, use of aseptic techniques to reduce infections, and safe use of restraints);

* Blame-free cultures (hold systems rather than individuals accountable, eliminate blame and punishment, root cause analysis to identify systems and process improvement opportunities);

* Collaborative practice in interdisciplinary teams to reduce the risk and to minimize the impact of errors that occur (strategies for improving safety, methods to improve communication and teamwork).

* Medication safety (technology improved labeling, and physician order entry).

Actionable Research

The five research studies in this publication highlight the concerns of AONE and JONA as they relate to work environment and workforce. Ma and associates, in a cross sectional study of over 17,000 nurses, examine factors affecting job satisfaction. One actionable finding for CNOs is the need to professionally challenge and recognize nurses who work on a particular unit for longer than two years. Nurses with more years of service tend to expect more autonomy, recognition, and opportunities. When these factors do not exist, dissatisfaction prevails.

McNeese-Smith and Crook conducted a survey of 412 nurses in 3 hospitals to evaluate relationships among work values, demographic variables, job stages, and nurse outcomes of job satisfaction, productivity, and organizational commitment. McNeese-Smith and Crook practically apply their findings and identify strategies to reduce nurse turnover. Actionable findings for consideration by CNOs include the use of a values instrument by the nurse manager and staff nurse at regular intervals followed by mutual goal setting based upon staff nurse values.

Larabee and associates conducted a nonexperimental predictive study of 90 nurses to investigate the relative influence of nurse attitudes, context of care, and structure of care on job satisfaction and intent to leave. The practical application of this study includes the potential of implementing a hardiness-training program (versus relaxation training) to enhance job satisfaction.

Krugman and Smith discuss the evaluation data from a charge nurse leadership model that created a new permanent promotional nursing leadership position for daily unit management. The results of this study guide nursing leadership toward best practices in developing emerging leaders.

Frank and associates present the survey results of accredited master's programs in nursing administration investigating current plans and future status. The actionable findings in this study relate to a CNO's support of graduate education for the nursing staff. The study found that graduate nursing programs are updating their curricula to adequately prepare nursing leaders to confront today's challenges.

Decisive Leadership

The pervasive reengineering and restructuring initiatives of the 1990s left many participants with a bitter taste. In search of a more responsible reconstruction, hospitals are turning toward their chief nursing officers to provide decisive, credible leadership based on substantive research findings. Historically, the literature has been replete with anecdotal accounts of single organization efforts. There is now a growing body of multi-hospital and large sample studies from which CNOs can extract useful empirical data to support decision-making. This publication contains five relevant and timely studies. Armed with these data, CNOs have an opportunity to identify new solutions that lie embedded in our current circumstance and to contribute to the quality of solutions throughout our organizations.

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