Case Study: Engagement of Expertise and Communication

Written on November 24, 2024 as an assignment for MHST 604: Leadership Roles in Health, a course in the Master of Nursing program at Athabasca University.

Learning Objectives

The learning objectives of this case study will be to (1) evaluate how leadership styles and values can affect engagement, (2) explore effective communication techniques and approaches to enhance stakeholder engagement, and (3) discuss approaches to aligning teams to a shared vision in order to ensure solutions effectively address problems. The target audience for this case study is nursing leaders, including educators, managers, professional practice, and quality and safety specialists, as some familiarity with nursing scope and workflow may be required.

Case Scenario

            This case scenario is based at a large, high-tech community hospital in an urban center. This hospital has integrated Epic as their electronic medical record software several years ago and the staff are proficient with the software. Two years ago, a working group was formed to explore the functionality of the Heparin Calculator within Epic. Continuous heparin infusions are ordered for specific patients, and administered according to a protocol that involves a series of nursing actions, including holds, rate changes, bolus doses, and regular monitoring of the patient’s blood work over the course of several nursing shifts. This protocol is complex and often misinterpreted by the nurses, causing many incidents of patient harm that are reported internally in the hospital. As a response to the ongoing incidents, the Heparin Calculator working group was formed to explore the calculator tool within Epic as a solution to the incidents. The tool is customizable to some degree, but the majority of its functionality and build is fixed, and it cannot be piloted on individual units because once it is live, it will be visible to all nurses in the hospital.

Question Break

1. Which roles should have representation in the working group, and who should comprise the stakeholder group?  Why would engaging various roles be beneficial?

2. Prior to exploring the calculator, what information does the working group need in order to plan and prioritize their tasks, and how can they gather that information?

   
   

            The Heparin Calculator core working group was composed of an Epic System Analyst, the Manager of the Analytics team, the Manager and Director of nursing Professional Practice, and the Director of Pharmacy. The group’s first step was to complete an environmental scan on current nursing practice with implementing the heparin protocol, and completing a data analysis on the main points of error in the workflow. They were able to demonstrate that the top three points of error in the workflow could theoretically be addressed, to varying degrees, by the Heparin Calculator. After establishing this as a background to their work, they were able to justify pursuing a long and complicated project toward functionalizing the calculator.

            Over the next year, the group experimented in a test environment with the Heparin Calculator, and conducted failure mode and effects analysis (FMEA), which is a method of evaluating processes for possible failures and correcting them prior to real harm occurring in a live environment (Institute for Healthcare Improvement, 2017). To do this, the team asked Clinical Nurse Educators to select nursing staff at random for demonstration meetings; the only information Educators were provided was that their staff would be testing out a new tool for the heparin protocol. The analyst would then set up the tool for the selected nursing staff, and watch the nurse as they interacted with the tool in a test scenario of administering a heparin infusion per protocol. This process was repeated with four nurses, each time obtaining feedback and recommendations from the nurse to modify parts of the calculator for clarity or efficiency. After this process review and modifications of the Heparin Calculator tool were completed, the working group felt they were ready for a live roll out to staff. However, at that point, another technology, called Interoperability, was also ready to be launched, and the Heparin Calculator was deprioritized by the organization. As such, the Heparin Calculator rollout was put on hold.

Question Break

3. What qualities should the selected nurses have to appropriately represent all nurses, who will be using this tool? How do you anticipate the limited information that the Educators were given might influence their selection of nurses, and consequently the validity of the FMEA?

4. What information should have been communicated to the Clinical Nurse Educators, as subject matter experts of nursing practice? How do you anticipate the lack of Educator engagement will affect the outcome of this project?

   
   

            One year later, Jane, a nurse by background, is hired into the role of Professional Practice Leader. Jane is a vocal individual, and she demonstrates an innovative, analytical, and critical approach to projects and issues early in her role. Jane’s Manager recognizes these strengths and decides to bring Jane into the Heparin Calculator Working Group, which is now being resumed after Interoperability has been live for nearly a year. Since Jane has a recent nursing background, Amanda is hoping Jane can bring some nursing expertise to the group as well.

            After Jane is brought up to speed on the working group progress and the functionality of the calculator, it is immediately obvious to Jane that the Heparin Calculator is critically flawed, especially from a nursing workflow perspective. Jane recognizes that the calculator does not solve the complexity of the heparin protocol, and the calculator is excessively detailed and sensitive, requiring focused expertise. The main issue Jane notes, however, is that the workflow of the calculator requires a complete contradiction of the Interoperability workflow which was introduced one year ago, and which nurses have just become competent at using. Jane is concerned that the Heparin calculator will cause significant confusion and present new major risks to heparin administration, with little to no resolution of existing problems.

            Jane voices these concerns to the working group, but the Directors involved do not seem to agree with Jane’s assessment of their severity. The Directors dismiss Jane’s concerns; they believe these issues are minor and can be resolved by staff education. To that point, Jane asks if stakeholders were involved with this project, and the analysts respond by reiterating the FMEA process they completed. Jane clarifies that she is referring to subject matter expert stakeholder engagement, such as the Clinical Nurse Educators, who are most familiar with nursing practice, nursing workflow, and educating the nurses. The team responds that the Educators were involved briefly early on in the project, and the Directors emphasize that the group has worked on this project for a long time and that the conversation now needs to be about timelines for the roll out.

            Jane, unsatisfied with the conversation that occurred in the working group, decides to find out what the Educators know of the Heparin Calculator. In her conversations with some of the Educators, she discovers that over the past year the Educators have not seen the tool and do not know how it works. Troubled by what she was discovering and the lack of nursing expertise in the Heparin Calculator working group, Jane meets directly with her Manager and insists that the Educators need to review the Heparin Calculator and be part of the decision on whether to go live with it. In agreement, Jane’s Manager convinces the working group to set up demonstrations and review meetings with the Educators. After these meetings, the Educators echo Jane’s initial concerns and do not believe that the tool will be well-received by or effective for the nurses. They are able to leverage the collective expertise of their group to convince the working group that the risks outweigh the benefits of the calculator. Through the Educator collaboration, however, the group is able to identify a new set of safer, more effective solutions that they can implement instead of the calculator to address the heparin protocol harm events.

Question Break

5. What leadership qualities, or leadership style does Jane have? What about follower qualities or style? What are Jane’s priorities, and how do those differ from the other members of leadership in this scenario?

6. What issues does Jane identify regarding the working group’s approach on this project, and what strategies does she apply to correct them?

Identifying the Problems

            To summarize, this case scenario demonstrated a situation where a working group was formed to functionalize a tool in response to a series of patient safety events. The working group did minimal staff and stakeholder engagement, was dissolved before the project was completed, and upon reforming, the group was trying to rush the final stage of the project since so many resources had already been utilized and a long period of time had passed. When a new member joined, however, the new member was able to approach the situation from a detached perspective and they recognized that the project had not followed an effective process and was not ready to be rolled out to the end users. While the new member’s concerns were dismissed by most of the working group, they were heard by their manager who was able to support the new member’s ideas and follow their lead on completing the necessary steps to roll out the project appropriately.

            The first problem that arose in this case study is the lack of role diversity and representation in the membership of the working group. One of the eight core elements of accelerating change identified by Kotter (2018) is to ensure that the guiding coalition, which is essentially a working group, is composed of “members from multiple layers of the hierarchy, [who] represent many functions, [and] receive information about the organization at all levels and ranks… [in order to] synthesize that information into new ways of working” (p. 13). In this case study, the members of the working group were Directors and Managers, and one analyst; there was a lack of representation from staff closer to the end user level. Consequently, there was no opportunity for clinical expertise to be consistently offered at each stage of decision-making in the development of the tool. Additionally, nurses are not only the end users of this tool being built, but they are also foundational for the success of hospital initiatives (MacLeod, 2016). If staff with the appropriate clinical expertise had been engaged earlier and more consistently throughout the process, it is likely that the resources spent on the project could have led to a more valuable, high-quality tool that the nurses could adopt, leading to better patient outcomes and decreased harm events (MacLeod, 2016).

In order to gain buy-in from nurses, however, leaders need to establish trusting, collaborative relationships with them, which raises another problem in this case study. The leadership style applied by the leaders in the working group was task-driven, transactional, and  of leadership that was focused on the development and implementation of the calculator tool, without building relationships with front line staff to engage them and gain their buy-in for the project (Cummings et al., 2010). The Directors on the working group were also dismissive of Jane’s concerns, demonstrating their lack of desire to collaborate or gather input from members at different levels of the hospital hierarchy. Collaboration, however, is consistently supported by the literature as much more effective for problem solving than authoritative approaches. Studies link improved patient outcomes to transformational leadership styles, rather than transactional, because transformational leadership is effective at engaging front line staff toward a culture shift of patient safety (Boamah et al., 2018; Cummings et al., 2010; Moraca et al., 2023). The reason for this is that through engagement from leadership, nurses become empowered and have a greater sense of ownership and accountability to their practice, which in turn leads to improved awareness of safety and identification of areas where harm may occur (Moraca et al., 2023). This means that engagement of front line staff will not only be beneficial at the implementation and sustainability stages of a project, but will also be beneficial throughout the assessment and planning stages of the project since nurses can provide accurate, efficient, and innovative solutions to the problems that affect them (Boamah et al., 2018; Moraca et al., 2023).

Another issue in this case study is a lack of clear, effective communication and transparency. This occurs between the working group and the Educators, who should be stakeholders in the initiative of the Heparin Calculator since they are subject matter experts. This also occurs between the working group and Jane when her concerns are dismissed and not further explored by the working group. On a larger scale, lack of communication or transparency is also occurring between the working group and the end users of the project as they are getting limited to no engagement. Communication is essential for leaders to be able to drive initiatives forward; high impact communication is when leaders are able to apply interpersonal influence to drive desired outcomes (Karen, 2023, n.p.). Communication is also beyond verbal messaging; it includes non-verbal cues like body language, facial expression, tone, and the channels through which communication occurs, all of which can be applied in various ways to affect importance, validity, and reliability of the message being delivered (Karen, 2023). A multitude of channels could have been utilized in this case study to engage nurses, engage stakeholders like Educators, or engage other clinical members and leaders in the development of the Heparin Calculator tool. The FMEA processes undertaken were a step in the right direction as they did allow some nurses to interact with the tool and provide feedback, but those sessions were limited to such a small number of nurses so they cannot be considered a truly representative sample of the nurses across the organization. Based on the lack of communication around the planning and development of the tool, the concern arises that the implementation and dissemination of the tool will be equally poorly communicated, which will add to the risk inherent with pushing an underdeveloped tool.

Solving the Case

            Jane took effective action by voicing her concerns, and doing her own investigation when her concerns were dismissed; however, she should not have had to. The approach to the project should have been to engage Clinical Nurse Educators early on in the development of the Heparin Calculator, so that they could have addressed how the functionalities of the calculator aligned with existing nursing practice. Additionally, ensuring that the clinical, front-line engagement was occurring from the early stages of the project would allow the Educators to prepare nurses early for the implementation of a new tool and new workflow, so that by the time the project was completed and live, nurses would be able to embrace it. Nurses’ reception of the tool is foundational to the project’s success (MacLeod, 2016). If the working group had engaged staff in this way, there would be greater likelihood that their project would be successful, and nursing uptake of the Heparin Calculator tool and the decrease in errors related to heparin would be more likely outcomes (MacLeod, 2016).

            It is also worth considering an additional solution, given the case that the working group had gotten to the point of Jane’s involvement in the same way. Even though the opportunities for early staff engagement had already passed, the working group should have listened to and addressed Jane’s concerns. Rather than pushing for the tool to be implemented live, the working group should have asked Jane to survey the Educators and staff about their current perceptions or understandings of the issues surrounding the heparin protocol, and to determine whether they want to be involved in the decision-making process of the Heparin Calculator tool. As demonstrated in the case study, the engagement of diverse roles led to innovative solutions to the heparin protocol issues which the working group had not considered.

Conclusion

Although the case ultimately arrived at a positive conclusion, the working group expended a significant amount of time and resources toward a tool that was not deemed to be effective by its end users, and that time and resource waste could have been mitigated if the approach had been more collaborative. Furthermore, Jane’s perceptions of the executive leadership culture in her organization is also likely marred by this experience where her justified concerns were dismissed and collaboration was undervalued. This case scenario demonstrated the value of collaborative approaches, as well as the value of confidence and perseverance in one’s ideas when they are founded on principles of knowledge sharing, breaking down of power dynamics, and clear, transparent communication. This scenario also allows you to self-reflect on what you would have done if you were in Jane’s position; how would you have approached the situation, and what personal values or principles of your leadership philosophy would be foundational to your approach?

References

Boamah, S. A., Spence Laschinger, H. K., Wong, C., Clarke, S. (2018). Effect of transformational leadership on job satisfaction and patient safety outcomes. Nursing Outlook 66(2): 180-189. DOI: 10.1016/j.outlook.2017.10.004

Cummings, G. G., MacGregor, T., Davey, M., Lee, H., Wong, C. A., Lo, E., Muise, M., Stafford, E. (2010). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies 47(3): 363-385. DOI: 10.1016/j.ijnurstu.2009.08.006

Fowler, K. (2023). High-impact communication in nursing leadership: An exploratory study. Nursing Management (Springhouse) 54(5): 14-25. DOI: 10.1097/nmg.0000000000000001

Institute for Healthcare Improvement. (2017). QI Essentials Toolkit: Failure Modes and Effects Analysis (FMEA) [PDF]. Web: https://www.med.unc.edu/ihqi/wp-content/uploads/sites/463/2022/02/QIToolkit_FailureModesandEffectsAnalysis-2.pdf

Kotter, J. (2018). 8 steps to accelerate change in your organization [PDF]. https://learning.athabascau.ca/content/enforced/17732-co_MHST604_60158_202409/Content/04_StudyGuide/04_Topic02/04_Unit06/04_Documents/Kotter_2018.pdf?isCourseFile=true&ou=17732

MacLeod, L. (2016). Aligning mission, vision, and values: The nurse leader’s role. Nurse Leader 14(6): 438-441. DOI: 10.1016/j.mnl.2016.09.005

Moraca, E., Zaghini, F., Fiorini, J., Sili, A. (2024). Nursing leadership style and error management culture: A scoping review. Leadership in Health Services 37(4): 526-547. DOI: 10.1108/LHS-12-2023-0099