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Introduced in 2003, the Clinical Nurse Leader (CNL) role is the first new nursing role introduced in more than 30 years. The hallmark of CNL practice is the management of client-centered care and clinical excellence at the point of care. As part of multifaceted efforts to implement the CNL role, understanding how an individual's self-efficacy with the identified role competencies changes over time has important implications for individuals, educational programs preparing CNLs, and health care organizations employing CNLs. In this study, preliminary psychometric analyses assessing the construct validity, reliability, and discriminant validity for a new state-specific scale (CNL Self-Efficacy Scale) that assesses nurses' perceptions of their ability to function effectively as a CNL are reported. Because self-confidence is a key predictor of successful role transition, job satisfaction, and job performance, measuring individuals' self-confidence with the core competencies associated with the CNL role over time will be important to gain the full benefit of this innovative, unit-based advanced generalist role.

Flawless execution rests in the hands of nurse managers. No one can work alone in health care any more. We are interdependent and know that the best outcomes happen when practices are organized around collegial supportive structures rather than autonomous competitive units. We are only as strong as our weakest link. If all managers see the big picture and look beyond their units for what is right for the common good, we will achieve high-reliability organizations in health care. In turn health care organizations will become very safe places to operate. Shared governance structures for nurse managers are the perfect vehicle to develop collaborative organizations and flawless execution, and to adopt high-reliability organization principles.

Creating a culture of patient safety is a critical goal of all patient care unit staff. An analysis of the key barriers to patient safety on a typical inpatient unit in an acute care hospital (unclear unit values), the fear of punishment for errors, the lack of systematic analysis of mistakes, the complexity of the nurses' work, and inadequate teamwork are presented. Nine practices to overcome these barriers and achieve patient safety are discussed.

Human beings are not machines. The patient safety literature documents the price we pay for excessive overtime, long hours, and no breaks. Disengaged staff, high vacancy rates, and turnover are the products of cultures that do not support a professional environment where nurses are seen as knowledge workers. At his retirement dinner, a factory worker accepted accolades for his years of dedicated service. In his farewell speech, he noted that for 40 years the factory used his hands but never his brains. His expertise and knowledge were never acknowledged or solicited. Consequently he watched in silence for years as directives came down from managers and leaders that were totally unrealistic and bore no relevance to the reality in which he worked. And he watched the initiatives fail. Unfortunately we in health care can create that exact situation if we do not incorporate time (slack) into the schedules of our knowledge workers so they can unleash their genius, reinvent health care, and fix health care from the inside out. Nurse leaders must be the architects of participation and allow this to happen.

Findings from a longitudinal study on the perceptions of the work environment and job satisfaction for new graduate nurses in the first 18 months of employment at a Magnet Midwestern urban academic pediatric medical center are described. The findings indicated that orientation assisted the new graduate to become confident in his/her clinical competence and work management. By 18 months, the new graduate felt satisfied with access to resources and the ability to participate in professional development opportunities. The results suggest that the new graduate nurse's career adjustment extends beyond mastering clinical skills and includes a lifestyle adjustment to a profession that requires service 24 hours a day, 7 days a week.

Shared leadership/governance offers the best environment for growth of the professional staff and for leaders and managers. Tisch (2004) writes that the power of the partnership begins with the recognition that no one can operate effectively in a vacuum and concludes with the premise that partnerships can redefine the traditional business relationships and transform them from adversarial to cooperative. This happens when the road is clearly delineated and guardrails are put in place as reminders of where the car should be on the road. With an atmosphere of learning and partnering to learn more, the leader's job becomes that of teacher, and mentor, and everyone is aligned around the journey to excellence with guardrails in place to monitor the journey.

The role of the nurse leader in patient safety can be characterized as follows: to establish the right culture; to infuse that culture with shared leadership so that the expert voice at the bedside is really defining the work; to possess the competencies necessary to coordinate and advance this complex initiative; and to forge both internal and external partnerships, because we will not be able to do this work alone. To further the work on this topic, nurse leaders who participated in the Nursing Leadership Congress are committed to identifying additional resources to help nurse leader colleagues drive patient safety efforts throughout their organizations.

In response to the nursing shortage, many health care organizations are utilizing a team approach to nursing care delivery. Although, the role of the charge nurse in these changing nursing care delivery models is a pivotal one to the effective and safe management of patient care units, many receive no leadership training. An educational program that hundreds of charge nurses have attended over the past 2 years is described. Strategies that organizations should consider when planning their own training are shared.

A computer information system, which can provide cost-saving measures useful in adequately allocating nursing staff in the face of decreasing patient stays, increasing patient admissions and discharges, and the unexpected transfers surrounding busy nursing units, is explored.

The state of the science as it relates to the stress-mediating role of social support in the health care work environment is explored. The ability to build a nursing leadership workforce is dependent upon a type of social support mechanism that mediates the inherent stress that comes along with managerial positions. Independent of the inevitable work-related stress associated with the nurse manager role, social support provided to current and aspiring nurse leaders is assumed to assist with coping and thriving in the work environment.

Labor costs for two versus one full-time nurse manager were compared. Results revealed reductions in nursing costs per patient day. These results suggest that innovative models may hold promise as organizations struggle to retain nurses and decrease costs.

Health care is just now feeling the effects of many years of neglect of serious attention to quality outcomes. We have many tools available now to change our thinking and to provide techniques to attain excellence in quality, such as Six Sigma and principals from Toyota. However, these techniques will only get us to a minimal level of quality. We need to change our questions, think the impossible, and break out of our old modes of thinking about quality. Zero defects are possible. We only have to take that quantum leap and think in new ways. We are posed on the edge of a quantum leap into new ways of thinking about quality. We will hear much more about nurse-sensitive indicators in the near future. Nurse leaders should change their questions now to attend to new models that will get us closer to the ultimate "impossible thinking" goal of zero defects in nurse-sensitive indicators of quality.

The most strategic asset a leader has to work with is the competency of her/his staff to perform at a level of excellence. The successful leader has the ability to create Communities of Practice within the organization that create highly bonded and effective communities of practice throughout the organization.

Retention problems will plague us for the near future. Blanchard and Waghorn (1997) believe that everyone wants to be magnificent, and not just ordinary. Unfortunately, often we expect only the ordinary and not the magnificent. People respond to our expectations. We can help staff to achieve magnificence by providing unconditional love and remembering that people are magnificent. Sometimes their behavior is a problem and certain things block the expression of their greatness, but all people are magnificent. If we create "sanctuaries of caring" where nurses and others are given the opportunity to achieve their innate nobility and magnificence, people will flock to participate in the noble and magnificent experience of patient care.

Many might challenge the concept of customerizing in the health care systems in the face of financial losses caused by the Balanced Budget Act. But, now more than ever, we should be obsessed with the customer and work relentlessly to understand that the procedure is not the end goal. The experience around that procedure will bond the patient to us, or create a consumer who is left with anger. The secret to success, according to Seybold (1998), is "It's the customer, stupid!" (pp. xvi). She also notes that all we have to do is to focus on making it easier for the customer to work with us. We should pick our customers' brains, visit them, learn what they care about, and make it easier for them to work with us. We can't afford not to.$

Health care in the new millennium will be different. We have a wonderful opportunity to live in a new paradigm of leadership and management that opens up myriad possibilities for innovations in health care and leadership. If leaders stand still and don't quickly adapt to the new demands, they will be killed as leaders in this new millennium. The next 20 years are only for those who can act and adapt quickly.

While the task of ascribing economic value to human caring is incredibly complex, Eisler (1998) reminds us that economic systems can and do change--and all our economic institutions are human creations. Humans can create new economic rules that recognize caring as the most foundational economically productive work (Eisler, 1998). In selected situations, the work of nursing has enormous economic value and new research continues to emerge which support our intuitive beliefs about the economic value of nursing's work (Levinson, Roter, & Frankel, 1997; Revans, 1964; Salmond, 1972). The future of health care requires that this work continues. The value of developing conscious economic inventions for nursing has the potential to assist nursing in its cost-effectiveness analysis, document the economic value of caring behaviors, inspire recruitment, and decrease the number of nurses leaving the profession. Nursing is challenged to shift its consciousness to one that is based on the value equation of quality, cost, and service. We are challenged to recognize the need to build a more equitable and humane economic system that gives real value to the work of caring, and to partner with other health care leaders, policy analysts, and economists in the process. Ultimately, developing economic measurements for the redefined work in nursing will require significant changes in economic measurements, institutions, rules as well as social norms, customs, and laws to quantify those goods not traditionally valued. The focus and energy of the nursing profession must move beyond overwhelming notions of loss and change; to challenging leadership to actively write and produce a better script for health in America beyond what we have developed over the past century. Indeed, this work is the requisite for the profession if what our children receive is the next level of enhancement from that which this generation obtained. It is no longer an option in creating a preferred future, it is nursing's mandate.

Excessive time was being spent by the emergency department (ED) staff, head nurse, and unit secretary on a complex 6-week manual self-scheduling system. This issue, plus inevitable errors and staff dissatisfaction, resulted in a manager-lead initiative to automate elements of the scheduling process using Microsoft Excel. The implementation of this initiative included: common coding of all 8-hour and 12-hour shifts, with each 4-hour period represented by a cell; the creation of a 6-week master schedule using the "count-if" function of Excel based on current staffing guidelines; staff time-off requests then entered by the department secretary; the head nurse, with staff input, then fine-tuned the schedule to provide even unit coverage. Outcomes of these changes included an increase in staff satisfaction, time saved by the head nurse, and staff work time saved because there was less arguing about the schedule. Ultimately, the automated self-scheduling method was expanded to the entire 700-bed hospital.

We all want health care to be delivered in an atmosphere of utmost integrity. However, integrity only occurs where there is courage to do the right thing in very difficult situations. Leaders must be very courageous to be successful. They must foster and build courage among their staff to create cultures in which the staff feel safe and supported to always act with integrity. We are not born with courage. We learn courage by eventually mastering situations in which we can act with less and less fear. The leader's obligation is to assess the environment and build opportunities for staff to work courageously with less and less fear as they master more difficult situations in their everyday lives.

Many individuals within the ambulatory division have benefited both personally and professionally as a result of this shared governance model and its concepts. Staff who rarely volunteered for projects became involved, and others developed their leadership skills. Although the ambulatory division's shared governance model did not reach maturity, many tasks were accomplished through collaborative efforts. As a result, there were many positive staff outcomes such as a greater understanding of their workplace, and a greater appreciation of their peers.

Uncivilized environments take their toll on people who work there. Cultures of distrust are created and there is no warmth, reverence, or love available for the healing work of health care. We can blame the staff, or we can look at ourselves and recognize that the staff is merely a reflection of ourselves. Gracious leaders create a gracious and loving staff who care for patients and their families in extraordinary ways.

The authors describe an elegant goal-driven program designed to prepare new nursing graduates to function optimally on a hospital unit by focusing first on their security and affiliative needs [belonging], and subsequently on their professional skill and knowledge acquisition. This developmental program has both a clear timeline and structure as well as well defined role expectations for the experienced RN guide/mentor, the orientee, and the unit's nurse manager and staff. The guide/mentors are carefully selected and prepared for their new roles as well. Shared goal-setting sessions are held weekly, along with three major evaluations during the first 90 days, with less frequent updates throughout the following year. This frequent feedback, reinforcement, and fine-tuning of goals allows the new graduate to gradually take on the full work load by the end of week 12 without feeling as overwhelmed or inadequate as those who are less carefully developed.

The leader in a nursing organization, whether it is the nurse manager or the nurse executive, is only as good as the positive synergistic relations that are developed with all parts of the organization. The converse is also true that the leader of any part of the organization is only as good as the synergistic relations she/he develops with the nurses and direct caregivers. Synchronicity is the mark of an effective organization and the hallmark of integrated organizations.

The authors compared the effects of the staff's perceptions of the culture in a LTC facility pre and post-intervention(s). One unit had significant architectural modification (physical intervention). On the second unit, efforts were directed toward culture change through management modification (social intervention through goal setting and role modeling). Lastly, both were compared to a third control unit where there was no planned change. On the unit with the social intervention model there was an attempt to support a "neighborhood" sense for residents and staff that would encourage residents to become more self-directed and self-sufficient rather than remain in the passive "good patient" role. Significant staff training resources and time were devoted to this effort. On the second unit, the architectural renovation sought to provide a distinctly home-like open, and relaxed atmosphere with a large, well-equipped day room. This encouraged closer resident and staff interactions and included a staff workstation that was part of the day room. On a third control unit, no changes were made.

There are many reasons people micro-manage in leadership positions. Anyone who has moved into the ranks of leadership from a clinical position will experience the angst of having to adjust to a "hands off" style and to trust that working through others to get the job done will work. The first step is to recognize this tendency and to admit that it is perfectly natural for a clinician to have to make the transition from doing it alone to working through others. The next step is to take the time to surround yourself with people who are capable of becoming better at certain specialized areas than you are and then allowing them to work. And finally, it is important to always assess your ability to work through others effectively. One of the most demoralizing behaviors a leader can display is that of communicating distrust and lack of confidence by continually interfering with a person's ability to work effectively.

Empowerment is defined as "moving decision making down to the lowest level where competent decisions can be made." In the hospital setting, this would most commonly be at the point of direct patient care or staff nurse level; however, this kind of empowerment requires an environment of autonomy where mutual trust and respect are encouraged. The empowerment process requires that staff be prepared to accept and effectively use expanded decision-making responsibilities. The professional accountabilities of the empowered nurse include having a sense of value about their work and willingness to provide the full scope of practice as well as ability to work as equal members of a comprehensive interdisciplinary team. In order to move into a fully empowered position, professional nurses need mentoring, education, awareness of political activism opportunities, and networking skills.

By the year 2000 13% of the general U.S. population will be made up of those over 65. Many states are seeking cost-effective ways to provide structure and some assistance for these individuals to help keep them in their own homes and out of institutions. The National Institute on Adult Daycare (NIAD) defines adult daycare as "a community-based program designed to meet the needs of minimally impaired adults through an individualized plan of care for part of a 24-hour day." Between 1980 and 1990 the number of centers grew from 1,200 to 3,000; by the year 2000, NIAD estimates that there will be a need for 10,000 adult daycare centers. The authors advise interested nurse entrepreneurs to consider the potential for establishing and running such centers and provide a roadmap for developing a business plan. A careful market analysis in your selected community should be the first step in the process of developing a workable business plan.

Authentic humility is strategic for the success of leaders. It is strategic from the perspective of the egotistically free relationship humility establishes with the staff, patients, and others. The lack of strategic humility explains the inevitable downfall of people who are motivated to lead by power and status. It also explains why leaders who always remember where they came from, and who are motivated by what they can do for patients and staff, succeed.

Implementation of PFC is considered a "rational" strategic choice in that it is thought to decrease the cost of providing health care while increasing the quality of services. Published research and evaluation studies that describe PFC are analyzed and the information is synthesized in hopes of discovering and describing commonalties among definitions, goals, and principles underlying PFC. The commonly accepted description of PFC is a model which "seeks to integrate the organization's values and culture with the operational excellence vision and processes to transform the institution into a customer-focused organization." Staff satisfaction is addressed by encouraging staff to plan and execute their clinical work in ways that are most responsive to patient needs. Grouping similar patients, bringing services closer to these patients, and appropriate cross-training of multidisciplinary care providers to enhance continuity of care are seen as the four most common elements described in most of the literature.

Leadership is the leading of creativity which leads to creative change. To innovate or die is the question that faces our health care future. It is no longer enough for us to operate with just our serial, mathematical thinking. We must also be concerned about the spirit and the heart and how we integrate this into whole brain thinking. The challenge for us is to constantly transform and rewire our brains through the creativity process and to rewire the processes of the places where we work. We know that we can cultivate and energize our organizations through the interplay of serial, parallel, and quantum thinking processes. But we can't wait. Health care and the world of nursing are changing rapidly. We need the creative processes to build the change needed for the future for the care of our patients.

It is important to examine the role of supervision in facilitating change and promoting the success of care delivery models using UAP in ambulatory care. Good supervision is a role expectation of all professional nurses, and is especially important in ambulatory settings where patient care objectives and patient diversity and complexity may not be well understood by UAP. The ramifications for nurse executives and managers include ensuring that organized opportunities to learn and be supported in supervision are part of the development of every staff nurse in the ambulatory setting. Sufficient time must be allocated in staffing models so that staff nurses can supervise appropriately. Nurse executives and managers must also assist staff nurses in finding rewards and satisfaction in supervision. Research must be designed to provide a database to assist in decisions about the optimal numbers of UAP that can be effectively used in ambulatory models without compromising patient outcomes. Research is also needed regarding the optimal number of UAP that can be effectively supervised by one staff nurse.

Cost savings, a goal in most health care settings, could be achieved by strategies leading to greater economic awareness. Nurse manager participation in budgeting, staff nurse awareness, and costs relative to linen and supply use were evaluated in this study. Staff who are aware of and use information about the relationship between their clinical behavior and cost savings could make a major impact on the financial health of their units.

Changes occurring in the health care industry are substantive and constitute a paradigm shift. Nurse managers can participate in shaping the health care organization of the future by understanding six critical areas of transformation and their driving forces.