Clinical Nurse Leadership and Performance Improvement on Surgical Unit 

Submitted by Cheryl A. Landry RN, MSN, CNL(c)

Tags: behavior clinical nurse leadership leadership skills performance surgical unit

Clinical Nurse Leadership and Performance Improvement on Surgical Unit 

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There are many ways that nurses can prevent harm to their patients. One method is to provide the necessary care that will promote only positive outcomes for their patients. Performance measures of the surgery unit that were identified and could be measured were antibiotic usage and venous thromboembolism prophylaxis. To effectively transform the nurses thought processes and gain buy-in to this performance improvement a cultural change was identified. The nurses needed a Clinical Nurse Leader (CNL) to assist them in understanding the need for this change and the benefits that would come about once this change was implemented. The CNL is a transformational leader who uses more than one style of leadership to get their employees to perform at a level of excellence. The styles of leadership used to adequately improve the performance on the surgery unit were affiliative and democratic.

Within every healthcare organization there must be at least one leader who has wisdom, a sense of right and wrong, and a vision for the potential of the organization. The vision of the leader must be embraced by the employees; the vision must be pertinent to their cause. Not only must a leader have a vision, so should the Clinical Nurse Leaders (CNL), they should also have exceptional interpersonal and communication skills that are necessary for a leader to be successful (Manion, 2005). The success of a leader is measured by the positive influential ability to get employees to reach the same goals of both the leader and the organization. Another way of assessing a leader is by the leadership style used to direct his employees. Leadership styles arise from leadership theories. Within this essay a description of the leadership style, characteristics, and role effectiveness that each leader must have will be discussed. There will also be a discussion of performance improvement and how transformational leadership can change a culture of noncompliant nursing staff to promote performance excellence within an organization.

Wheatley (2000) stated “we have sought prediction and control, and have also charged leaders with providing everything that was absent from the machine: vision, inspiration, intelligence, and courage” (p. 1).  A new era has brought innovation to the minds of leaders and employees. A leader establishes a vision, autonomy, encourages esprit de corps, and empowers employees to think critically (De Pree, 2000).

When leading, two leadership styles are used. The style of leadership used depends on the situation. Mills (2007) stated “Goleman observes that leaders who achieved the best results used a variety of styles, which they adapted to the situation” (p. 129). Two styles of leadership that an effective leader may use includes:  democratic and affiliative. These styles of leadership are based on the transformational leadership theory.

Democratic Leadership Style

The democratic style of leadership allows the employee to take part in goal setting and the decision making process. Information or suggestions received from employees is taken into consideration and used when feasible. The democratic leader although, allows for input from employees, the final decision is made by leader. However, when a particular area or topic is unfamiliar, the democratic leader is receptive to ideas and suggestions (Mills, 2007). The democratic leadership behaviors that enhance effectiveness includes:  encourages others to take part in the decision making process, develops skills of employees, allows the team members to be in control of their own work receiving the kudos deserved; this motivates members of the team to work harder (Krause, 2007).

Affiliative Leadership Style

Mills (2007) stated “leaders put their people first. This leadership style is generally considered positive and is especially useful when attempting to build esprit de corps among team members, increase morale of rebuild broken trust” (p. 133). The behaviors associated with this style of leadership includes:  a positive approach to employees, passive and prefers not to anger team members, waxes and wanes when it comes to making a decision. The leadership behaviors of an affiliative leader may enhance or hinder team effective. Putting the team members first and taking into consideration that all assignments are completed on time and the team members are satisfied with the contribution of the leader is very important. As an affiliative leader, these behaviors may also hinder the team’s effectiveness. The negative behaviors include:  the leader’s desire to not anger team members. This passive behavior will inhibit the leader when it is time to correct employees who do not follow the instructions given them, or fear of critiquing an employee’s contributions. The affiliative leader will also find it difficult to make a decision or make a choice at a critical time.

Transformational Leadership Theory

The transformational leadership theory is the basis for optimal leadership styles. Krause (2007) stated “the developmental nature of this style helps leaders achieve results by influencing, motivating, and inspiring employees over whom they may or may not have direct supervision” (p. 1). Both the democratic and affiliative leadership styles influence, motivates, and inspires employees. Following the transformational leadership theory and exhibiting the behaviors of both a democratic and affiliative leader will continue to allow for leadership effectiveness.

According to Piccolo & Colquitt (2004)

Transformational leaders have the ability to raise follower task performance while also encouraging organizational citizenship behavior-those “extra-role” behaviors that are not discretionary and not directly recognized by an organization’s formal reward system and that help improve organizational functioning (p. 1).

As a transformational leader, if the employee is able to relate to the mission and vision of an organization, the employee will play a large part in the positive efforts toward building the organization and be personally rewarded for its success.

Performance Measurement

Hall, Doran, & Pink (2004), suggested that “valid indicators of hospital quality are based on outcomes of care experienced by the patient, the nursing staff and the hospital system” (p. 1). One effort in question is the measure of performance of the nursing staff who utilizes nurse indicators. These indicators are specifically designated for the surgical unit of any hospital that has an operating room.  The focus for this essay will be the Washington, DC Veterans Affairs Medical Center (VAMC), the unit of interest will be 2D General Surgery.

Quality Control

According to Marquis & Huston (2009), “quality control, a specific type of controlling refers to activities that are used to evaluate, monitor, or regulate services rendered to consumers” (p. 538). The quality control relevant to the surgical unit requires a plan for ongoing monitoring, auditing, and evaluating of findings that will provide a basis for performance improvement. The Agency for Healthcare Research and Quality (2005) stated “the Surgical Care Improvement Project (SCIP) is designed to provide hospitals with effective strategies to reduce four common surgical complications-surgical wound infections, blood clots, perioperative heart attack, and ventilator-associated pneumonia” (p. 1). The interventions used to combat these surgical complications are evidence based practices and as time goes on changes will occur to improve the outcomes of surgical patients.


Surgical complications can take a measurable toll on a patient’s health and safety causing prolonged treatment and increased lengths of hospital stays. To prevent these complications specific measures are performed that will aid in the recovery of the patient. Two performance measures that will be focused on include appropriated antibiotic usage and venous thromboembolism prophylaxis (VTE). These two measures were chosen because the nursing staff plays a crucial role in the compliance and the effectiveness of both antibiotic and VTE prophylaxis usage.


To have performance excellence with the two previously stated measures there must be a reason to look at them. Hall, Doran, & Pink (2004) also suggested that “The outcomes of nursing care should demonstrate three characteristics: (1) they should be measurable by efficient, valid, and reliable methods; (2) they should be relevant to the patient, healthcare setting, and or government; and (3) they should be represent the intended or unintended effects of hospital nursing care” (p. 1). If the data shows that the performance is less than perfect than there is room for improvement. If the data shows perfect performance then there is no reason to routinely look at this measure, random monitoring will therefore be required. Next, a benchmark is performed. Marquis & Huston (2009) defines benchmarking as “the process of measuring products, practices, and services against best performing organizations” (p. 540). When benchmarking the SCIP performance will be reviewed. The review will assess how well or how bad they are doing and then goals will be set to reach and surpass the other organization’s performance. Surpassing the benchmark will require the VAMC to set their SCIP performance numbers higher than that of the benchmark.

Auditing, Processes and Tool

The process is initiated with an audit tool which was specifically designed to meet the needs of the quality control. The tool has information that is relevant to the data that is being collected such as the patient’s name, type of surgery, date of surgery, diagnosis, antibiotic order, antibiotic order followed, VTE ordered, VTE order followed and comments. The bottom of each column will be totaled once the sheet is completely filled out. The information used to complete the audit sheets is obtained from different sources. The majority of information is obtained from the Computerized Patient Record System (CPRS). The CPRS contains physician orders, operative notes, nurse’s notes and medications, all of which are needed to complete the auditing process. Once the orders of new admissions are reviewed the patients are physically assessed to ensure that the orders have been accurately carried out by visualizing that the patient is wearing TED hose and SCD pumps.

Data will be collected daily for all new admissions for the first quarter (October 2008 to December 2008). This data will prove to be a baseline for future data collection. Future data collection will be done on a specific number of randomly selected patient charts. The data will be analyzed for discrepancies, patterns, and identification of staff members who needs additional education.

The desired healthcare outcomes should be comparable to the background and knowledge base of the nursing staff. This is not to say that quality care cannot be achieved without outcomes being obtained. Staff can deliver poor care and quality of performance may be deemed as excellent. There are many indicators of quality care and outcomes measurement is only one. To use outcomes alone to measure quality care will produce data that is not valid and unreliable (Marquis & Huston, 2009).

Integrating Leadership

To produce the quality of care needed to be considered an organization of excellence, a transformation of the culture of nursing staff must take place. This transformation must be one that promotes autonomy, and integrity. In order for the nursing staff to achieve this new behavior they must be led by a leader of change. If the CNL is to aid or lead the way in the transformation process there must first be a belief in their own mission, vision, roles and implementations for performance improvement. There are many roles that a leader must take into account and have the capability to live up to them. There is no contract that can be written that will eliminate all risk of integrity loss. A baseline requirement for leaders working to build a unit or organization is a necessary requirement. The staff may not understand every aspect of how or why the system is being developed, but if people believe that the leaders are honest and have their best interests at heart, they will generally be willing to support change. Conversely even the most brilliant scientific proposal will fall flat if led by an individual who is not regarded as having the highest integrity.

Marquis & Huston (2009) suggested the leadership roles include:

  1. Encourages followers to be actively involved in the quality control process.
  2. Clearly communicates expected standards of care to subordinates.
  3. Encourages the setting of high standards to maximize quality instead of setting minimum safety standards.
  4. Embraces and champions quality improvement as an ongoing process.
  5. Uses control as a method of determining why goals were not met.
  6. Distinguishes between clinical standards and resource utilization standards, ensuring that patients receive at least minimally acceptable levels of quality of care.
  7. Supports /actively participates in research efforts to identify and measure nursing sensitive patient outcomes (p. 538).

Once the staff recognizes that the leader is one who holds all of these attributes, the leader will gain the trust of the staff and will then have buy-in into the performance improvement strategies that will prevent negative outcomes. Marquis & Huston (2009), suggested that “inspiring subordinates to establish and achieve high standards of care is a leadership skill. Leader’s role model high standards in their own nursing care and encourage subordinates to seek maximum rather than minimum standards” (p. 539).

Outcomes of Performance Measures

The first data collection from the surgery unit was completed for the month of October 2008. The data showed that there were 76 admissions to the unit, 57 of these patients were surgical patients, and 19 patients were admitted for other reasons such as testing, observation, surgical workup, and overflow from other units. 30 patients required anticoagulant orders, and 46 patients required antibiotic orders, and 38 patients required TED and SCD orders. Only seven patients were ordered antibiotics that were administered improperly. The errors discovered in the data collection of the seven patients revealed that they received too many doses, too few doses or the doses were held causing a delay in the care of the patient. The other data that was collected was evaluated and deemed free of mistakes.

Action Plan to Improve Performance

Because the data collected showed that the errors were in part due to nursing negligence, education of the nursing staff is a major part of the action plan to improve performance of antibiotic usage. Education will include the purpose of collecting the data on antibiotic administration, the importance of antibiotic administration and the consequences that arise when the medication is not administered or administered improperly. Each month the data will be presented in the performance improvement meeting and disseminated to all of the committee members. Either this data will show an increase in compliance, a decrease in compliance, or here have been no changes in compliance. This information will be posted on the unit to show how well or how poorly the staff compliance has been; hopefully this posting will spark a drive in the staff to be strive to do better. October’s data is the baseline for the months to follow, all data collected after October hopefully will show a decrease in errors of antibiotic usage.


An evaluation of each month’s data will be discussed in the monthly staff meeting. No matter how well or how poorly the staff is doing, there will always be room for the staff to improve their performance. During this meeting attempts at nursing empowerment will be made by giving positive feedback and reiterating the necessary mindsets that are needed and welcoming the behaviors of staff that support quality and productivity (Marquis &Huston, 2009).


It is extremely important for all disciplines in the hospital work together to provide excellent care to the veterans of the VAMC. For all staff members to actively take part in SCIP there must be a transformational leader who utilizes the many attributes needed to motivate the staff towards excellence, instill autonomy, and empower the staff to think critically. Gilkey (1999) suggested that “four major initiatives will be prominent in nursing’s journey toward to the future. They include nursing professionals’ relationships with physicians and other health professionals; the way the profession meets its accountabilities to the public, the composition, and development of the nursing workforce, and the adaptation of nursing science to changing practice” (p. 5).

The changing practices include the CNL encouraging and pushing nurses to become actively involved in shared governance and becoming responsible for the roles that they play on their units. These nurses must recognize that nursing is changing from just patient care and many more tasks are being expected of the nursing staff to accomplish. Effectiveness in performance measures and excellence after performance improvement will paramount in the nursing leader’s role. The nursing workforce is made up of many cultures, ages, and educational backgrounds. Diversity will continue because nursing will be in the mainstream of education.

The incorporation of performance measures and quality outcomes in tomorrow’s basic nursing curriculum will only further prepare the nurse for a rewarding career.


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