IP Stakeholders Series: Chief Nursing Officers

By Kelly M. Pyrek

The engagement of key organizational senior leaders in infection prevention and control is essential to ensure optimal patient care and to promote quality throughout the healthcare institution. One such stakeholder is the chief nursing officer (CNO), with whom the organization's infection preventionist(s) should cultivate a collegial relationship. As IPs monitor how healthcare workers implement infection prevention and control-related principles and practices, the CNO can help ensuring resource and both clinical and administrative leadership support as the foundation to successfully implement these prevention measures. As Nelson, et al. (2011) observe, "Leaders play a pivotal role in hospital initiatives to improve quality … It is essential for those personnel in leadership to work collaboratively in order to not only enhance healthcare environments but also make it safer for patients."
 
Several years ago, Sanjay Saint, MD, MPH, emphasized that leadership plays a critical role in hospital infection prevention and control pro-grams. Through a three-phase study of invited hospitals whose lead infection preventionist had completed a quantitative survey on HAI prevention, Saint, et al. (2010) sought to better to understand which behaviors are exhibited by leaders who are successful at implementing HAI prevention practices in U.S. hospitals. A survey in phase one, data collection in phase two, and site interviews in phase three contributed to the findings.
 
As Saint, et al. (2010) note, “We found that successful leaders cultivated a culture of clinical excellence and effectively communicated it to staff; focused on overcoming barriers and dealt directly with resistant staff or process issues that impeded prevention of HAI; inspired their employees; and thought strategically while acting locally, which involved politicking before crucial committee votes, leveraging personal prestige to move initiatives forward, and forming partnerships across disciplines. Hospital epidemiologists and infection preventionists often played more important leadership roles in their hospital’s patient safety activities than did senior executives.”
 
The researchers cite the differences between transactional leaders -- guide their followers by ensuring that roles and tasks are clearly specified and by using reward and punishment as motivation – and transformational leaders – those who inspire their followers to see beyond their perceived self interest. The researchers point out, “Although the distinction between transactional and transformational leadership styles is important, the lines between the two are blurred. Indeed, some believe that the styles are complementary and that perhaps transformational leadership builds on transactional leadership.” Saint, et al. (2010) conclude that leadership plays a key role in infection prevention and that the challenging process of translating the findings of infection prevention research into practice can be eased by leaders who heed the advice and experiences of their colleagues.
 
That may be easier said than done in the fast-paced hospital environment. "Nurse executives and infection preventionists do not have enough face time, primarily due to the workload of both positions but also many hospitals do not have a forum where both professionals are included," says Joan Shinkus Clark, DNP, RN, NEA-BC, CENP, FACHE, FAAN, president of the American Organization of Nurse Executives (AONE). "Since infection perfectionists typically do not fall under nursing, they do not attend most nursing meetings, which can create a knowledge gap. That is not to say that there are exceptions to this in terms of CNO/IP partnerships, but it is not the rule. Sharon Williamson, infection prevention program director Texas Health Resources, told me, 'the most valuable information to an infection preventionists comes from visiting frontline nurses on the units and just listening to their challenges. Unfortunately, increasing regulatory requirements, along with other priorities, impact the infection preventionist’s ability to spend more time on the unit.'"
 
Clark joined the Texas Health Resources leadership team in 2008, assuming overall responsibility for the nursing enterprise across the Texas Health Resources System. Texas Health has 25 acute-care and short-stay hospitals that are owned, operated, joint-ventured or affiliated with the system. It has more than 3,800 licensed beds, more than 21,000 employees of fully-owned/operated facilities plus 1,400 employees of consolidated joint ventures, and counts more than 5,500 physicians with active staff privileges at its hospitals. In her system role, Clark has responsibility for advancing strategic nursing initiatives and represents nursing at the senior executive level.
 
Clark adds, "One way to improve communication and collaboration is to create an intentional IP liaison program on each nursing unit and ancillary area where there are identified IP champions. These champions come to a monthly meeting to discuss challenges on the nursing and infection prevention sides with preventing healthcare-acquired infections (HAI). These meetings are a time to share best practices among the patient care areas. They are also an opportunity for infection preventionists to provide tip sheets and HAI data for champions to bring back to their areas for posting and present at department meetings. Another benefit of incorporating IPs into nursing leadership meetings is improved understanding about the challenges nursing faces."
 
An improved understanding of each stakeholder's clinical challenges and fiscal/operational realities can help foster an effective partnership.
 
"It is important to explain the rationale or science behind requests for documentation or additional steps to a procedure/process and not to assume each party speaks the same and understands why a certain procedure is done," Clark says. "As Williamson said to me, 'I’ve found once nurses become IPs and see the other side, they often say that they wished they had known the rationale when they were a bedside nurse.' Another challenge is infection preventionists are not always nurses so they may not understand the terminology used by clinicians. Patience and a willingness to learn is required by both parties to overcome communications gaps."

Clark points to a real-world example of how nurse executives and IPs can work together to address patient safety imperatives, healthcare-acquired infection rates, and outcomes. "Texas Health Resources recently formed an HAI Task force co-chaired by the IP and CNO," she explains. "Through this work, the CNO and IP developed a working relationship and improved their understanding of the issues from both sides of the equation. As a result, the CNO became much more engaged as a leader for HAI prevention."
 
Clark continues, "Developing regular forums in which nurse executives and IPs work together to review progress on specific initiatives, set mutual goals and create joint action plans. These forums help foster relationships between IPs and nurse leaders and creates an opportunity to understand the challenges each side faces."
 
References:
 
Nelson S, Stone PW, Jordan S, Pogorzelska M, Halpin H, Vanneman M and Larson E. Patient Safety Climate: Variation in Perceptions by In-fection Preventionists and Quality Directors. Interdisciplinary Perspectives on Infectious Diseases. Vol. 2011, Article ID 357121. Accessed at: http://www.cumc.columbia.edu/studies/pnice/pdf/Nelson.pdf
 
Saint SS, Kowalski CP, Banaszak Holl J, Forman J, Damschroder L and Krein SL. The Importance of Leadership in Preventing HealthcareAssociated Infection: Results of a Multisite Qualitative Study. Infect Control Hosp Epidemiol. 2010;31:901-907.