Nancy Dickenson-Hazard, former CEO of the Honor Society of Nursing, Sigma Theta Tau International (STTI), continues her interview of Bonnie Wesorick, founder and chairman emerita of Elsevier CPMRC Resource Center.
Nancy Dickenson-Hazard: What is happening to help people develop these practice platforms, now that they’ve invested all this money in EHR? Are they putting in totally new systems, or are they incorporating compatible side-by-side systems?
: That’s a great question! Some people thought the reason things weren’t better was because a new product was needed, a new vendor. That wasn’t the issue. The problem was, they didn’t do the fundamental pre-implementation work. They didn’t strengthen their platform. Nor did they ask, “How is this going to help clarify scope of practice, integrate competencies and promote development of the plan of care? How is it going to help us to do the continuum of care?” Those questions weren’t asked, but that’s all part of the practice platform.
We’ve designed a methodology that addresses each of those elements, so we can say, “Here’s what we can do to help you have clarity on scope of practice. If you have variance in scope of practice, you will never have safety for the patient and the organization. It will always matter who takes care of them.” Addressing these issues is key to our success.
Dickenson-Hazard: When you say “we,” you mean CPM Resource Center?
Wesorick: Yes. We developed what we call the CPM Framework, which addresses and guides the cultural practice transformation. You need to have the tools and resources to do it, but there’s fundamental work you have to do. We have met with hundreds of thousands of clinicians to clarify their scopes of practice. You won’t believe how much work that is. We ask, “What is your competency in that?” That’s related to evidence-based practice. We ask, “What is your integrated competency as a team? How do you do that?” And we ask, “What tools do you need?” Then, we not only give them the tools, we integrate them into their technology. So, the inevitable outcome is a change in behavior.
You know who I thought of when I was trying to figure out how we were going to do this? Believe it or not, it was Florence Nightingale. I went back and read everything about her, and she said something I’ll never forget. This hospital is so busy and in such a hurry, she said, that it’s easy to slide into bad habits before we are aware. Over time, nursing became task dominated, not scope-of-practice dominated. We focused on policy and procedure, rather than basing practice upon evidence. These are polarities, but nursing was practiced in a unipolar world. In other words, patterns that exist in our practice platform today are 150 years old!
Dickenson-Hazard: This goes back to the polarity management assessment you pulled together.
Wesorick: It’s absolutely key. Yes, we need to have good policies, procedures and tasks, but we must also have clarity about scope of practice, and we must support clinicians to live within that professional framework, within their accountability as a professional. That’s why CPM Resource Center has the outcomes we have, because we’re guided by a framework that strengthens the practice platform, and technology helps us reach that higher goal.
Dickenson-Hazard: Can you tell me what your outcomes are in terms of an integrated practice platform? At this point, how many have adopted that?
Wesorick: All of our sites are heading that way. We have more than 370 sites, and it’s changing all the time, but here’s the issue. Some of them think that technology will take care of it, but it won’t. It just won’t. They have to do the practice-platform work. So they’re all at different levels, but I would estimate that, in the past year, we’ve had at least 10 already-automated sites—a couple of them recognized for being among the most automated hospitals in the country—that have now come back and said, “We thought technology would take care of this, but it hasn’t. We have to work on our practice platform. Can you help us?”
Dickenson-Hazard: Describe what that entails. What does working on their practice platform involve?
Wesorick: The first thing we do is tell them, “Let’s assess your practice platform.” That’s where we start. We have an interdisciplinary team. There are more than 60 of us on that team, so we can very quickly go in and help them make that assessment. In fact, we now have a new Web-based tool to help them access a hospital’s practice platform. And what that means, simply, is: Is everybody clear about what matters?
Before the IOM report came out, we identified 10 fundamental elements, the same ones that later showed up in the report. For example, are people clear about what matters most? We call these core beliefs. We ask, “Do you have the communication skills needed to achieve integration across all your disciplines and with patients and families?” We assess partnerships, with one another, across their units and across the continuum. We look at how clear people are on their scopes of practice, how clear they are on other disciplines’ scopes of practice and whether or not they’ve been integrated. We ask about tools they’re using. Are they evidence-based? Is that evidence at their fingertips? Is it preventive in nature, to protect the patients, and how well are they documenting this?
So we took the 10 fundamental elements and developed an approach to help people change the behaviors needed to make it happen. And they’re all integrated. We use what we call implementation methodology, which has evolved over the last 30 years.
Dickenson-Hazard: Awesome! So you know more than 370 organizations—and counting—that are headed in the direction of integrated platforms and looking at how they continue to develop their own platforms. That’s a major sea change in the way care is delivered. How is this being integrated into education?
: It’s so slow it’s not even funny. Recently, however, interprofessional research and educational and clinical integration programs are being done, and we are working closely with those efforts. There’s a program, now international, called “Crossing the Borders”— in other words, expanding beyond the borders and doing interdisciplinary integration in education and practice—that had a conference this last year. In fact, the CPM Resource Center was selected to present five abstracts at that conference—the only entity with that many. So we are fortunate enough to be a part of that work, and it is making a big difference. We are also a part of the National Academy of Practice
, the only academy addressing the call for interdisciplinary education and practice.
Dickenson-Hazard: Have there been any strategies developed or discussed around working with national education organizations to move this forward?
Wesorick: Absolutely! That’s why we’re so excited about the grant I mentioned earlier, because that grant is going to help make that happen. I don’t pretend to understand all the thinking that has gone on in that development but, at the national level, it has become clear that we must have integration. You can’t expect a student to come out of education, move into the real world and be integrated, because they’ve never learned that.
Dickenson-Hazard: So The Bonnie Wesorick Center for Health Care Transformation may become a model for that national program.
Wesorick: Yes, because we can tie the academic and the clinical together, and people can come and see what interdisciplinary integration looks like at the point of care. Taking it out of theory into reality—bridging the two—can set the world on fire, but there really does need to be a stimulus at the federal level to make that happen. We need that kind of support.
Dickenson-Hazard: As you know, this connection between practice and academia has been talked about for decades but has not gained traction. There’s an opportunity here for a model that does gain traction.
Wesorick: The reason I started this work is because a student challenged me. You know, Jim Mattson wrote about that in the article you mentioned earlier. A student told me I was living a lie. When I asked what she meant, she said, “You taught me the beauty and essence of practice, and you sent me to a world where nobody can work like that. What are you going to do about that?” She helped me realize I had to go back into the real world and make it happen. As a result, I quit my job, went back for my master’s degree and, for two years, asked how we make this happen. That’s where the roots for the clinical practice model began.
Dickenson-Hazard: It’s interesting how comments of colleagues—whether students or peers—can change the direction of our thinking and acting.
Wesorick: That is so true! I was on an airplane not too long ago, on a four-hour flight. I work from the moment I get on a plane to when I get off, so I was working. About an hour into the flight, the man sitting next to me taps me on the shoulder and says, “Do you have a minute? Can I ask you a question?” And I said, “Well, certainly!” And he says, “Are you Bonnie?” I had my papers out, you know, and was getting ready for a presentation. I said, “Yes.” And he said, “Well, is your work about creating healthy work cultures?” I said, “Yes, it is.” And he said, “I can’t help but notice that you are a nurse. How is it you that you left nursing?”
I’m sure I had this terrible look on my face, and I said, “I haven’t left nursing. This is some of the highest level nursing I’ve done!” And he said, “How did you get into this healthy culture work?” And I said to him, “Oh, it’s a long story.” He said, “Start from the beginning.” And I said, “Well, it’s the hardest work I’ve ever done.” He said, “What gave you the courage to do it?” And I said, “No one has ever asked me that question before, and I’d like to honor it. Do you mind if I sit and reflect on it?”
When I got around to answering his question, I told him, “When you asked about courage, I thought of people. When I see people being courageous, it makes me want to be courageous. When I look back, I realize there are three people who gave me courage in different ways.”
One of them, I told him, was a colleague who came to me and said, “I want you to be the first to know,” and I said, “First to know what?” And she said, “I’m leaving.” I was just sick about it. And I said, “Why are you leaving?” She looked me in the eye and said, “Bonnie, I need to leave before I lose my soul.” She was the first person who caused me to verbalize the realities around me. I tend to think, if you can’t do your assignment, you have to work harder, you have learn more, you have to read harder. And she said, “Don’t you know it doesn’t have to be like this?” And I thought, “Well, darn, then the assumption is we should do something about it!” And I did.
The second person was also a colleague, one of my closest. I walked into the unit one day, and they said, “Have you heard?” I said, “Heard what?” “That Tom took his life last night.” I have to tell you, Nancy, I remember being frozen in place, thinking I can’t breathe; I can’t move. But my first reaction was, and it stays with me as though it happened yesterday, was to ask, “What role did I play in his death?”
I was his significant colleague. How could I have missed this? He was one of the best colleagues I ever worked with. He was brilliant, compassionate and passionate. He walked into the unit every day and said, “What do you need? Is there anything you need?” He was a learner. How could I have missed it?
I was privileged to have walked on this journey with him. And I remember saying to the others on the unit, “This isn’t a good place. Do you know what we do around here? We work each other to death, and we very seldom stop to say thank you, to tell our colleagues how important their work is, to say, ‘Do you know I couldn’t do my work without you?’” My lesson from him was, we cannot do our work and heal others unless we first care for one another. That’s what he taught me.
The third example I shared with him was the student I mentioned earlier who told me I was living a lie. And I said to that young man, my travel companion: “That’s why I made the commitment to devote the rest of my life to creating cultures worthy. Worthy of what? Worthy of the people who walk through these doors every day to do this care and worthy of the trust that people give you.”
And he said to me, “There is something you need to know.” And I said, “What’s that?” He said, “I’m 39. I am an extremely successful businessman. I’m a multimillionaire. I am one of six executives at a worldwide Fortune 500 company, and I was the fifth man on our six-man executive team to have a heart attack. I had it at age 38, and I know what causes it. It’s the stress of the culture.” And he said, “You keep up this important work.”
And all I could think was, “We are the healers for this humanity, and if we can’t have this healing culture to do our work, it’s not going to work. You can have all the technology you want, all the tools you want, but you have to do the fundamental work to create a place where it’s OK to be tired when you leave work because you are doing such important work.”
Dickenson-Hazard: It’s obvious, Bonnie, that, in Act 3, you haven’t slowed down much, particularly in terms of your passion. Someone said to me recently, “It’s not retirement, it’s ‘preferment,’ because retirement provides the opportunity to do the things you prefer and are most meaningful to you.” You’ve been very fortunate, You’ve had a long career of doing work that is not only meaningful to you but which has really contributed to the profession and elevated nursing to much higher levels of care delivery. Thank you for that.
Wesorick: Well, thank you. You know, somebody mentioned retirement, and I said, “You know, I don’t like that word. That is not a part of my life, but I am trying to work less, and I am doing very well at that. My GPS says, “Recalculating!” I think I’m just recalculating, you know, trying to balance.
Dickenson-Hazard: It is about balance. Any other comments, things you want to talk about before we wind this up?
Wesorick: You know, it took awhile for me to realize that there is no one person, no one program, no one department, no one discipline, no one setting that will ever determine the quality of care for an individual. It’s all of us. If we do not work together—in partnership—we can’t achieve that great goal. We are constantly looking at what we need to do to achieve that, but we have to first care for one another.
And you know, this work has only evolved the way it has because of the passion, role modeling and commitment of colleagues with whom we are so privileged every day to work. When I do the engagement overviews I mentioned earlier, you can’t imagine the stories people come up and share with me. They tell me: “This is what I needed. I didn’t think there was any hope. Do you think this could happen here?” They know they need to do this work but don’t know how, and they’re thrilled when they see their organization say, “Yes, we are going to commit to do this work.”
Dickenson-Hazard: That’s awesome. And I know that rejuvenates you, when you hear them say, “This is what I’ve been looking for. This is the type of care I want to give.” That has got to be so rewarding!
Wesorick: It is. I’ve been very blessed, and I’ve never taken it for granted. I could never have done any of this had I not come from such strong family roots, where we learned to love and laugh and play and care for one another. It started when I was little. And then, I have a husband who is a gift from God and a team that, every day, just inspires me.
James Mattson, editor, RNL: Thank you, Bonnie and Nancy, for sharing your conversation with readers of Reflections on Nursing Leadership. Nancy, you asked Bonnie about her Act 3. Would you share with the readers of RNL about your Act 3, what you’re doing these days?
Dickenson-Hazard: Well, let me think here, how it started. When I left Sigma, I had about four big tasks that I agreed to complete, not only for Sigma but also for some other organizations. That helped me get through the transition period of not working 70 hours a week, of not having to report for duty and not traveling. I did a lot of thinking before I left as well as afterward about what it is I wanted to continue to contribute, where I could have the biggest impact. I have had, as you both know, a real passion for leadership for years. I was frankly very concerned about the next generation of nurse leaders to come along, and I wasn’t sure they were at all prepared or had even identified themselves as leaders. So part of the time I was at Sigma, we worked really hard to develop that leadership component, and there are some wonderful programs at STTI. It’s a fabulous place for people to jumpstart their careers.
But I wondered, “What can I do as an individual?” As chance would have it, a new nursing executive contacted me and said, “Will you coach me on how to be a good executive, how to work with boards?” And I said, “Sure. I’ll do that.” Then, as I got to thinking about it, I thought, “I really do need some sort of credibility if I’m going to hold myself out as a coach.” So I went back for a post-master’s program in executive coaching and learned a tremendous amount about how to bring out the best in people.
Since finishing that program, my purpose in life has been to develop and unleash the leadership potential of nurses through personal leadership planning and coaching. I have done that now for the past four years, working with CEOs, CNOs, faculty members, practice individuals, managers and so forth. It is extremely rewarding work, and it really is fulfilling my “preferment” need.
Wesorick: In our work with hospitals, we constantly recognize the need for strong leadership and, when it’s not there, how it impacts every single person working there and every patient. So the work you’re doing is so important!
Dickenson-Hazard: I was very concerned that nurses were coming up the ranks—the career ladder, so to speak—but nobody was really giving attention to helping them develop their leadership skills, skills that are both tactical and adaptive. It’s those types of skills that allow you to be an authentic and true leader. Anyway, my practice has blossomed very nicely, and I try to keep it at a reasonable pace. I’ve really enjoyed it. RNL