nancyEDRN

Healthcare is a constantly shifting industry, becoming more tedious with new politicians elected to office, added regulations for patient experience, updates to service line policies, etc. With these increasing standards and complex expectations, emergency departments struggle to maintain a sense of belonging for staff, therefore losing staff faster than they can replace them. Decreased retention and decreased time getting to know their coworkers and leaders causes increased personnel stress levels making it crucial to understand the leadership model best suited to role model for staff in such a dynamic and complex environment. Transformational leadership is embraced by leaders who want to make changes to not only individual staff but also social systems to develop staff into future leaders. With a transformational leadership structure, there will be improvements in staff engagement, staff retention, and overall patient outcomes. Hospital establishments are also dissimilar to other industry establishments in that units are open 24/7, 365 days a year, with staff working around the clock. Therefore, it is essential to have constant, dependable leadership and supervision, day and night. Each shift, for leaders and staff, is full of interruptions, patient volume ebbs and flows, high-intensity decision-making, and unforeseen patient interactions ranging from civil to hostile. Through all these changes, emergency department leaders need their departments and staff ready to provide comprehensive emergency care on non-emergent, emergent, and mass casualty scales at all times. According to the University of Massachusetts Global1, transformational leaders "know how to encourage, inspire and motivate employees to perform in ways that create meaningful change. The result is an engaged workforce that's empowered to innovate and help shape an organization's future success.” Therefore, transformational leaders encourage staff to be a part of the solution to any problem so that they will be motivated to make the changes necessary to keep the department prepared, equipped, organized, and successful. As mentioned, decreased retention has been a huge problem for emergency departments and the healthcare industry overall. Patient experience numbers are increasing while simultaneously seeing decreasing healthcare worker satisfaction. Burnout rises as staff-to-patient ratios increase, the ability to take breaks decreases, and growing stressful environments intensify physical and mental strain. Emergency department leadership's attempts to keep tenured staff positive and motivated while welcoming more new staff require all leaders to have a transformational approach. "Highly reliable organizations have high scores regarding employee engagement, patient satisfaction and patient outcomes which are correlative to transformational leadership, strong shared governance and eventually great retention"2. Leadership attempt to stay collaborative and in touch through routine staff meetings and staff rounding, but the focus of a transformational leader should include how to influence direct reports and other followers to find what motivates them on an individual level. The emergency department I worked in for eight years prided itself in feeling like family, but unfortunately, after a few years, I noticed, whether due to burnout, personal life changes, or other career advancement opportunities, a large turnover of staff hit our emergency department causing the leadership to have a difficult time maintaining the current culture and feeling of work "family.” The role of the Clinical Nurse Coordinators (CNCs), charge nurses with direct reports and service line autonomy, in our emergency department provides a holistic approach to maintaining culture by role modeling overall leadership expectations on shift and taking the time to get to know the new staff personally, caring for each and every one individually to empower and motivate them. The idea of this trusted position role modeling behaviors to staff is explained through idealized influence, a concept encompassed by transformational leadership. Idealized influence "is defined as having transformational leaders who behave in ways that result in their being role models for their followers. These leaders are admired, respected, and trusted since followers identify with the leaders and want to emulate them. One of the things leaders do to earn this credit is to consider the needs of others over their own personal needs. They can be counted on to do the right thing, demonstrating high standards of ethical and moral conduct, and avoid using power for personal gain"3. Transformational leaders who value idealized influence engender trust, admiration, loyalty, and respect among followers. Trust is at the foundation of these components, building loyalty as trust grows, with staff knowing things will run smoothly through trusting who is in charge. Transformational leaders realize how their actions affect outcomes and how knowing each staff member's personal strengths and needs allow the catering of decisions on shift. From my years of leadership experience, leaders strive to create a safe haven where honest communication can be shared mutually, show trust in staff knowledge and decisions, create a non-judgmental learning environment, and take the time to recognize staff contributions. Through role modeling, these behaviors to staff, staff, in turn, treat each other with the same respect and extra attention. "Transformational leadership with an emphasis on "idealized influence" is a model of leadership that, when applied, will lead to successful healthcare teams and organizations in local as well as globalized operational environments. This, in turn, will lead to high-quality and responsive healthcare being provided, which benefits patient and organization, as well as other supportive and protective organizations and the community"3. The goal is to bolster an environment of inclusion, influencing and encouraging each other to grow as leaders and create an environment of success. In conclusion, transformational leaders are passionate about bridging the gap of the "us versus them" mentality between leadership and staff to build a foundation of trust through collaboration, flexibility, and honest feedback, thus creating an environment supported by idealized influence. In healthcare, especially in emergency departments, transformational leadership is particularly important to run an erratic environment smoothly. If leaders decide to utilize a transformational leadership model, they will see improved department trust, staff retention, and team dynamics, thus leading to improved core measures and patient outcomes. Transformational leaders role model for and inspire future leaders, creating a transcended environment staff want to remain a part of and new staff seek out. The result is a team that nothing and nobody can stop. References/Resources 1 What is transformational leadership? Understanding the impact of inspirational guidance: UMass Global Administration 2 Transformational Leadership: One Emergency Department's Journey: Sigma Repository 3 EMS Leadership Part 5: Idealized Influence Transformational Leadership in EMS: HMP Global

Unfortunately, I also witnessed leadership-to-staff bias much more often than I expected. I felt, as a charge nurse, I needed to advocate for staff when leaders made snap decisions from staff looks and the few instances they saw those staff versus what I witnessed working alongside staff day in and day out.

Emergency Department staff see every type of unique patient, from differing religious, ethnic, cultural, and racial backgrounds to varying gender preferences, weight, age, insurance coverage, and income status. This constantly changing, stressful environment can easily lead to implicit bias and microaggression from both patients and staff working in emergency departments. Implicit bias is a form of prejudice that occurs both unconsciously and unintentionally and affects judgment, decisions, and behavior. A common behavior associated with bias is microaggression, a brief verbal, behavioral, or environmental indignity, whether intentional or unintentional, that communicates hostile, derogatory, or negative prejudicial insult. Implicit bias can lead to patient and staff discrimination causing safety concerns and care inequality. With leadership awareness and staff training, unconscious bias can be mitigated, as well as witnessed microaggression decreased. Implicit bias is most commonly seen causing intentional microaggression when patients single out staff, police presence, and other patients through biases instilled in them from their past experiences, such as influence from gang activity, white supremacy groups, religious affiliation, etc. Unfortunately, it is not limited to patients. Healthcare workers are susceptible to implicit bias through assumptions that a patient or even a coworker is going to behave in a certain way, perhaps by how they look (I.e., covered in tattoos, ear gauges, or piercings), without any other interactions. According to a study by Anthony Greenwald and M.R. Benaji in 19951, implicit bias does not escape any person since "much of our social behavior is driven by learned stereotypes that operate automatically – and therefore unconsciously – when we interact with other people.” These learned stereotypes are built into our subconscious throughout our whole life, therefore, not easily swayed. "The ability to distinguish friend from foe helped early humans survive, and the ability to quickly and automatically categorize people is a fundamental quality of the human mind. Categories give order to life, and every day, we group other people into categories based on social and other characteristics. This is the foundation of stereotypes, prejudice, and, ultimately, discrimination"2. Emergency Department personnel create a "thick skin" in an attempt to keep daily biased insults and behaviors from affecting them. However, these repeated interactions have undue consequences. One specific example, personally witnessed by myself as a charge nurse, involved an African American nurse who had recently graduated nursing school and had just begun her emergency department career. A white supremacist patient came into one of her assigned rooms, and after taking one look at her, instead of seeing a person with feelings, he saw her only by her skin color. He called her inappropriate slurs and cast harsh glances. We were able to find the patient another nurse, but you could visibly see how their interaction, however brief, had deeply impacted her. She was distraught for the remainder of her shift and transformed from that one instance for the rest of her life. She will have implicit bias around certain types of patients from that situation. Healthcare workers, especially in emergency departments, witness patients and coworkers living up to their implicit biases consistently as patients, family, and staff often act their foulest during some of the worst moments in their lives. Haggins, MD, who researches health care access disparities and improving care to historically marginalized populations for the Department of Emergency Medicine at the University of Michigan Medical School in Ann Arbor, stated in 20223, "ED providers face gaps in knowledge of patient's medical histories, a lack of long-standing patient-provider relationships, and numerous work distractions - all of which can translate into medical decisions based on stereotypes or gut feelings instead of best medical practices." Some common examples of these stereotypes or gut feelings, just to name a few, include seeing a disheveled, foul-smelling, lethargic person and automatically assuming the person is homeless and either drunk or on drugs; seeing someone covered in tattoos, especially on their neck and face and thinking they probably have a dark past and jail time; or seeing someone come in with a gunshot wound saying, "This just happened to me randomly, I don't know why, I was just standing there" and staff immediately saying to each other, "Yeah right, we hear that all the time, you did something to provoke this.” Healthcare workers cannot change patient bias, but there are ways they can change their own biases to give more empathetic, compassionate care to the underserved, marginalized groups holding their main implicit biases. Haggins, MD3 reported two crucial thought changes to correct staff bias, thus preventing microaggression toward vulnerable populations. First, understanding structural competency through awareness of patient legal, social, and economic policies that affect a patient's access to health care and community resources. Second, becoming culturally humble through a willingness to learn from patients as their own experts from their lived experiences. According to The Joint Commission2, "with organizational support, skills training, and cognitive resources, clinicians who are highly motivated" can control biased thoughts to improve patient safety and care disparities. In conclusion, healthcare workers must strive to become more self-aware, to recognize and overcome their own implicit biases to understand each individual person with different lived experiences that shaped them into who they are today. They must strive to be more compassionate, even to those they previously thought to be undeserving. They must intentionally change their thinking with each biased thought to catch themselves in those thoughts and give their coworkers and patients a chance to prove them wrong. Lastly, staff must offer evidence-based medical care, under any circumstance, to prevent their biases from diverging from the care that should be provided to all patients alike. The first step to change is acknowledging one's biases and being willing to adapt. References/Resources 1The Development of Implicit Attitudes: Psychological Science 2 Quick Safety 23: Implicit bias in health care: The Joint Commission 3 Bias in the emergency department: Association of American Medical Colleges