- Email: [email protected]
Developing the new frontline manager
Developing the New Frontline Manager Lauren Arnold, PhD, RN, and Greg Nelson
ou’re a critical care nurse— and a darn good one. Your clinical skills, selfless hours of sacrifice, and ability to quickly quell multiple crises have paid off. You’ve captured the attention of the chief nursing officer (CNO), and she wants to promote you to frontline manger. You’re flattered and proud—and reticent. You’ve seen other high-flying colleagues crash and burn in less than a year under the added responsibility and pressure. So you turn down the CNO’s offer, and your hospital is the big loser.
Y
Similar scenes play out hundreds of times each week in health care systems across the country. Frontline nurse managers are leaving in droves, and, for multiple reasons, not enough qualified nurses are stepping up to fill these leadership roles. Health care systems are too preoccupied with other priorities—reimbursement issues, quality initiatives, patient satisfaction programs, staffing shortages, and more—to give nurse leadership problems the attention they deserve, so the leadership door continues to revolve. Why is that? Part of the problem is that, traditionally, nursing hasn’t done a good job of demonstrating its valueproducing contributions to really focus management’s attention. As the caring profession, nursing hasn’t quite achieved the level of visible standing required to garner resources from cash-strapped organizations. Increasingly, 50 Nurse Leader
the industry is being challenged to structure and support nursing organizations to create strategic value for hospitals and their customers. For instance, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2005 National Patient Safety Goals1 and other leadership and performance standards2 stress the importance of using metrics as a framework to help nurses demonstrate value to senior management in terms of quality, safety, physician/nurse relationships, and patient satisfaction. These measures will help the nursing profession articulate its organizational value like never before. And frontline nurse leaders will be at the center of that attention because they drive clinical unit performance. December 2004
LEAPING INTO FIRST-TIME LEADERSHIP ROLES Frontline managers arguably hold the most important jobs in the hospital. They implement every decision, every new policy or program, every new regulation. Without strong leadership at this level, organizations struggle. The shortage of skilled frontline managers, primarily a result of retirements, budget cutbacks, and younger nurses unwilling or unable to take on the responsibility, is well documented.3 By 2010, the average age of the working nurse is projected to be 50;4 the average age of frontline managers is projected to be even higher. This trend has caused many organizations to rush some nurses into leadership roles without adequate preparation, often without notice. Many are evaluated on their clinical knowledge, organizing proficiency, and ability to communicate effectively with physicians and patients—skills that are prized at the bedside but do not constitute the complete set of competencies and skills required to succeed as leaders. For many nurses, the transition to first-time leader is the most formidable career challenge they will ever face. Overnight, their universe expands from a limited number of patients to responsibility for care delivered by dozens of direct reports across a unit. The new leaders become management representatives and change agents expected to articulate and implement policy and assume accountability for those policy implications. Their daily reality checks for the first time include managing payroll, resolving conflict, and coaching employees to improved performance, all in addition to making rounds and talking with physicians, patients, and family members. Considering the job complexity and increasing demands, it’s not surprising that just 38% of health care workers have a high degree of confidence in their supervisors’ abilities.5 No wonder so many first-time leaders fail. The consequences can be devastating: quality drops, errors persist, morale sinks, and turnover and its related costs skyrocket.
SCULPTING THE NEW FRONTLINE MANAGER Given the current turmoil in health care, it’s not surprising that two thirds of health care organizations do not have a systematic process of identifying and developing candidates for leadership positions.5 What may be more revealing is that one third of them report that they indeed have such a system in place. More health care organizations are beginning to take a strategic approach to developing leaders by adopting behavior-based competency modeling that has been used in the business sector since the early 1970s. These organizations link strategic goals and unit performance with behavior competency models. Then they use this framework to identify leaders, develop them, evaluate their performance, and promote them. This succession management process ensures a constant flow of competent, motivated people through your leadership pipeline. And when this pipeline is visible to all, your units will have the tools to demonstrate value contribution; career pathways will be unequivocal, and staff will have greater confidence that the organization is headed in the right direction. December 2004
FIVE STEPS TO PREPARING NURSE LEADERS FOR SUCCESS There are three types of nurse leaders: • Frontline or people leaders who directly manage staff and oversee the value-producing work of the unit • Operational leaders who are experienced in managing others and counted on to drive change and affect staff performance across multiple units • Strategic leaders who are called on to drive organizational performance system-wide Although the degree of skill, knowledge, ability, and motivation differs for each level, the basic framework for building a leadership pipeline will be the same, regardless of whether you’re constructing a plan for frontline, operational, or strategic leaders. Five steps are essential to building an effective leadership development pipeline: 1. Gaining management support 2. Creating a success profile of the ideal leader 3. Determining fundamental leadership skills and gaps 4. Training for gain 5. Sustaining momentum
Step 1: Gaining Management Support for the Leadership Pipeline How do you gain leadership buy-in for a succession management program when so many other fires are burning out of control? By addressing it on management’s terms: value-based contributions. What are the key goals you expect to address—quality, retention, patient throughput? Present your case for leadership development as it applies to achieving these organizational strategic priorities with a realistic timeline for delivery.
Step 2: Creating a Success Profile of the Ideal Leader What knowledge, skills, abilities, and motivations are required by your leaders for your organization to succeed? Success profiles are excellent tools to help answer that question. Nurses and hospitals need a common set of parameters for defining individual success profiles. Objective, behavior-based competency modeling provides this framework for selection, development, retention, performance management, and promotion. Competencies define effective performance behaviors. They enable the organization to create clear and realistic expectations that nurses, managers, and senior leadership can agree on, thereby eliminating surprises, emotions, and “gut feelings.” This process isn’t as complex as it may sound. A group of senior-level nurses at one large U.S. health system did it by creating a profile of their ideal nurse leaders. The goal was to establish a common set of competencies and skills among all levels of nurse leaders so that system-wide strategies could be implemented uniformly and rapidly. To begin, the group selected appropriate competencies that had been used for more than a generation to identify successful leadership attributes in the business sector. After receiving input and feedback from other experts and senior-level Nurse Leader 51
nursing executives, the group narrowed the list to 10 competencies and then identified specific behavioral sets for each nurse leadership level. For example, the chief nursing officer is expected to have a different level of skill in managing resources than is a nursing director. This set of competencies formed the foundation for interview and selection guides and ultimately can form the foundation for performance management and learning and development. Of course, you don’t have to start from scratch to create your own ideal nurse. A number of organizations have issued standards and competencies that you can reference. The American Society for Healthcare Human Resources Administration, for instance, defines 11 different behavioral competencies for nurse middle managers, ranging from results orientation, skilled communications, and team building to agent for change, commitment to service, collaboration, analytical thinking, and talent development, among others.6 Besides using competency modeling in your leadership success profile, don’t overlook the importance of motivational fit. Some individuals, despite exemplary clinical skills, interpersonal behavioral traits, and a strong commitment to the nursing profession, simply don’t want to take leadership roles. They don’t want the hassle and extra responsibility that comes with assuming a seemingly impossible job—carrying added administrative burdens, dealing with 50 different personalities, and being further removed from delivering bedside care. Interviewing and selecting candidates based on an agreed set of competencies will increase the likelihood that you will be able to screen out candidates who lack the motivational fit for a challenging nurse leader role. Without the proper motivation for leading others, candidates fail.
Step 3: Determining Fundamental Leadership Skills and Gaps Using the competency model as a measuring stick to assess the leadership potential of current and future leaders is the next step in creating a pipeline to serve the organization. This assessment process will reveal an individual’s strengths and vulnerabilities, as well as what competency gaps exist organization-wide. For instance, as nurses advance in their careers, they often rely on personal traits, styles, or approaches to help them achieve goals. In leadership positions, however, these favored styles can become problems or derailers when leaders overuse them. Although this is particularly true of senior-level leaders, it’s also prevalent among frontline managers. For example, a nurse who once received praise for close attention to detail now is perceived by direct reports and peers as a micromanaging leader. The individual who avoids the ambiguous situations that confront health care leaders every day and chooses instead to focus on short-term projects he or she can control seems short-sighted. The person who perceives her- or himself as maintaining high standards comes across as overly critical. Common assessment tools include: • Written tests that reveal critical thinking skills 52 Nurse Leader
• Behavioral interviewing that asks probing questions into how one goes about making decisions • 360-degree surveys that gather feedback from managers, peers, direct reports, and others • Executive assessment centers for more-senior leaders that provide a well-rounded picture of leadership capability through “day-in-the-life” simulations When choosing an assessment instrument, it’s absolutely essential that you define in advance how the results will be used, match assessment results against the success profile you created, and openly communicate the process so that it is perceived as fair. Properly completed assessments will clearly show where you need to focus development efforts and which individuals don’t have what it takes to succeed in a leadership role.
Step 4: Training for Gain Once leadership skill gaps have been identified, design a curriculum to close those gaps. Few people are naturalborn leaders; most learn leadership behavior—good and bad—from others. And that’s how your people can learn leadership skills—by instructive role modeling. A blended learning approach that integrates classroom learning, exercises, simulations, role-playing, and even online interactivity is best. Assigned mentors and coaches help fledgling and senior leaders learn how to get through rough patches unscathed. The University of Pittsburgh Medical Center (UPMC) matches its leadership development participants with working projects. The value created through these projects has approached $500,000 in real savings over 2 years, with potential long-term saving opportunities estimated in excess of $38 million.7 UPMC’s success has evolved into the Health Care Leadership Academy,8 a national leadership development program in partnership with Development Dimensions International that targets frontline, operational, and strategic leaders for intense 1- or 2-week development training sessions. The academy will graduate its third group of leaders this spring. Regardless of curriculum approach, administrators must ensure that training goals are clear and meaningful for all participants. Whenever possible, link the training that supervisors and direct reports receive, such as empowerment training and team building.
Step 5: Sustaining Momentum Injecting a degree of tension into learning ensures that training sticks with your leaders and they use their newfound skills on the job. For instance, many organizations make leadership development training mandatory and back it up with consequences for those who miss sessions. Others go much further by measuring how leaders’ behaviors have improved after training. You can sustain momentum even more through additional classroom learning, online/situational learning, project work, and temporary “stretch” assignments in addition to proactive mentoring, coaching, and role modeling. And you can extend the length of your pipeline by training December 2004
your current leaders in how to identify nurses with the potential to assume future leadership roles.
OVERCOMING RESISTANCE Although few would argue that ensuring a dependable nurse leadership pipeline is a good idea, the action must come from within the organization. The plan must be measurable with metrics linked to the organization’s strategic priorities. It must be endorsed and actively supported by an influential management sponsor. And it must be sold to and embraced by the leadership ranks and staff. There’s little question that you will receive resistance. Both management and staff will contend that there is precious little time and that resources are scarce to invest in a leadership pipeline. Your plan may be perceived as making little difference or as just another “program of the month.” And it requires a significant shift in perception of the organization’s hiring, orientation, promotion, and performance evaluation systems—systems that have been in place for decades. But the results for the organizations that have taken the time, invested the resources, and bought into the behavior-based competency model for building a leadership pipeline show a significant return on their investment, with reduced turnover, higher levels of staff engagement, and improved job performance. That’s strategic value any senior manager can understand. References 1. Joint Commission on Accreditation of Healthcare Organizations. 2005 national patient safety goals. Oakbrook Terrace (IL): Joint Commission on Accreditation of Healthcare Organizations; 2004. 2. Joint Commission on Accreditation of Healthcare Organizations. Leadership and performance improvement standards. Oakbrook Terrace (IL): Joint Commission on Accreditation of Healthcare Organizations; 2004. 3. American Hospital Association. 4. Buerhaus P, Staiger D, Auerbach D. Implications of an aging registered nurse workforce. JAMA 2000;283:2948-54. 5. Development Dimensions International. 2003-2004 Leadership forecast. Pittsburgh: Development Dimensions International; 2003. 6. American Hospital Association’s Commission on Workforce for Hospitals and Health Systems. In our hands: how hospital leaders can build a thriving workforce. Chicago: American Hospital Association’s Commission on Workforce for Hospitals and Health Systems; 2002. p. 33. 7. Wolf G, Bradle J, Nelson G. Bridging the strategic leadership gap: a model program for transformational change. J Nurs Admin. In press. 8. Health Care Leadership Academy [Home page]. Available at: www.hcleadershipacademy.org.
Lauren Arnold, PhD, RN, is a nurse executive for the Advisory Board Company. Greg Nelson is vice president of the Health Care Practice Group for Development Dimensions International in Pittsburgh. He can be reached at [email protected]. 1541-4612/2004/$ see front matter Copyright 2004 by Elsevier Inc. doi:10.1016/j.mnl.2004.10.003
December 2004
Nurse Leader 53
ou’re a critical care nurse— and a darn good one. Your clinical skills, selfless hours of sacrifice, and ability to quickly quell multiple crises have paid off. You’ve captured the attention of the chief nursing officer (CNO), and she wants to promote you to frontline manger. You’re flattered and proud—and reticent. You’ve seen other high-flying colleagues crash and burn in less than a year under the added responsibility and pressure. So you turn down the CNO’s offer, and your hospital is the big loser.
Y
Similar scenes play out hundreds of times each week in health care systems across the country. Frontline nurse managers are leaving in droves, and, for multiple reasons, not enough qualified nurses are stepping up to fill these leadership roles. Health care systems are too preoccupied with other priorities—reimbursement issues, quality initiatives, patient satisfaction programs, staffing shortages, and more—to give nurse leadership problems the attention they deserve, so the leadership door continues to revolve. Why is that? Part of the problem is that, traditionally, nursing hasn’t done a good job of demonstrating its valueproducing contributions to really focus management’s attention. As the caring profession, nursing hasn’t quite achieved the level of visible standing required to garner resources from cash-strapped organizations. Increasingly, 50 Nurse Leader
the industry is being challenged to structure and support nursing organizations to create strategic value for hospitals and their customers. For instance, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2005 National Patient Safety Goals1 and other leadership and performance standards2 stress the importance of using metrics as a framework to help nurses demonstrate value to senior management in terms of quality, safety, physician/nurse relationships, and patient satisfaction. These measures will help the nursing profession articulate its organizational value like never before. And frontline nurse leaders will be at the center of that attention because they drive clinical unit performance. December 2004
LEAPING INTO FIRST-TIME LEADERSHIP ROLES Frontline managers arguably hold the most important jobs in the hospital. They implement every decision, every new policy or program, every new regulation. Without strong leadership at this level, organizations struggle. The shortage of skilled frontline managers, primarily a result of retirements, budget cutbacks, and younger nurses unwilling or unable to take on the responsibility, is well documented.3 By 2010, the average age of the working nurse is projected to be 50;4 the average age of frontline managers is projected to be even higher. This trend has caused many organizations to rush some nurses into leadership roles without adequate preparation, often without notice. Many are evaluated on their clinical knowledge, organizing proficiency, and ability to communicate effectively with physicians and patients—skills that are prized at the bedside but do not constitute the complete set of competencies and skills required to succeed as leaders. For many nurses, the transition to first-time leader is the most formidable career challenge they will ever face. Overnight, their universe expands from a limited number of patients to responsibility for care delivered by dozens of direct reports across a unit. The new leaders become management representatives and change agents expected to articulate and implement policy and assume accountability for those policy implications. Their daily reality checks for the first time include managing payroll, resolving conflict, and coaching employees to improved performance, all in addition to making rounds and talking with physicians, patients, and family members. Considering the job complexity and increasing demands, it’s not surprising that just 38% of health care workers have a high degree of confidence in their supervisors’ abilities.5 No wonder so many first-time leaders fail. The consequences can be devastating: quality drops, errors persist, morale sinks, and turnover and its related costs skyrocket.
SCULPTING THE NEW FRONTLINE MANAGER Given the current turmoil in health care, it’s not surprising that two thirds of health care organizations do not have a systematic process of identifying and developing candidates for leadership positions.5 What may be more revealing is that one third of them report that they indeed have such a system in place. More health care organizations are beginning to take a strategic approach to developing leaders by adopting behavior-based competency modeling that has been used in the business sector since the early 1970s. These organizations link strategic goals and unit performance with behavior competency models. Then they use this framework to identify leaders, develop them, evaluate their performance, and promote them. This succession management process ensures a constant flow of competent, motivated people through your leadership pipeline. And when this pipeline is visible to all, your units will have the tools to demonstrate value contribution; career pathways will be unequivocal, and staff will have greater confidence that the organization is headed in the right direction. December 2004
FIVE STEPS TO PREPARING NURSE LEADERS FOR SUCCESS There are three types of nurse leaders: • Frontline or people leaders who directly manage staff and oversee the value-producing work of the unit • Operational leaders who are experienced in managing others and counted on to drive change and affect staff performance across multiple units • Strategic leaders who are called on to drive organizational performance system-wide Although the degree of skill, knowledge, ability, and motivation differs for each level, the basic framework for building a leadership pipeline will be the same, regardless of whether you’re constructing a plan for frontline, operational, or strategic leaders. Five steps are essential to building an effective leadership development pipeline: 1. Gaining management support 2. Creating a success profile of the ideal leader 3. Determining fundamental leadership skills and gaps 4. Training for gain 5. Sustaining momentum
Step 1: Gaining Management Support for the Leadership Pipeline How do you gain leadership buy-in for a succession management program when so many other fires are burning out of control? By addressing it on management’s terms: value-based contributions. What are the key goals you expect to address—quality, retention, patient throughput? Present your case for leadership development as it applies to achieving these organizational strategic priorities with a realistic timeline for delivery.
Step 2: Creating a Success Profile of the Ideal Leader What knowledge, skills, abilities, and motivations are required by your leaders for your organization to succeed? Success profiles are excellent tools to help answer that question. Nurses and hospitals need a common set of parameters for defining individual success profiles. Objective, behavior-based competency modeling provides this framework for selection, development, retention, performance management, and promotion. Competencies define effective performance behaviors. They enable the organization to create clear and realistic expectations that nurses, managers, and senior leadership can agree on, thereby eliminating surprises, emotions, and “gut feelings.” This process isn’t as complex as it may sound. A group of senior-level nurses at one large U.S. health system did it by creating a profile of their ideal nurse leaders. The goal was to establish a common set of competencies and skills among all levels of nurse leaders so that system-wide strategies could be implemented uniformly and rapidly. To begin, the group selected appropriate competencies that had been used for more than a generation to identify successful leadership attributes in the business sector. After receiving input and feedback from other experts and senior-level Nurse Leader 51
nursing executives, the group narrowed the list to 10 competencies and then identified specific behavioral sets for each nurse leadership level. For example, the chief nursing officer is expected to have a different level of skill in managing resources than is a nursing director. This set of competencies formed the foundation for interview and selection guides and ultimately can form the foundation for performance management and learning and development. Of course, you don’t have to start from scratch to create your own ideal nurse. A number of organizations have issued standards and competencies that you can reference. The American Society for Healthcare Human Resources Administration, for instance, defines 11 different behavioral competencies for nurse middle managers, ranging from results orientation, skilled communications, and team building to agent for change, commitment to service, collaboration, analytical thinking, and talent development, among others.6 Besides using competency modeling in your leadership success profile, don’t overlook the importance of motivational fit. Some individuals, despite exemplary clinical skills, interpersonal behavioral traits, and a strong commitment to the nursing profession, simply don’t want to take leadership roles. They don’t want the hassle and extra responsibility that comes with assuming a seemingly impossible job—carrying added administrative burdens, dealing with 50 different personalities, and being further removed from delivering bedside care. Interviewing and selecting candidates based on an agreed set of competencies will increase the likelihood that you will be able to screen out candidates who lack the motivational fit for a challenging nurse leader role. Without the proper motivation for leading others, candidates fail.
Step 3: Determining Fundamental Leadership Skills and Gaps Using the competency model as a measuring stick to assess the leadership potential of current and future leaders is the next step in creating a pipeline to serve the organization. This assessment process will reveal an individual’s strengths and vulnerabilities, as well as what competency gaps exist organization-wide. For instance, as nurses advance in their careers, they often rely on personal traits, styles, or approaches to help them achieve goals. In leadership positions, however, these favored styles can become problems or derailers when leaders overuse them. Although this is particularly true of senior-level leaders, it’s also prevalent among frontline managers. For example, a nurse who once received praise for close attention to detail now is perceived by direct reports and peers as a micromanaging leader. The individual who avoids the ambiguous situations that confront health care leaders every day and chooses instead to focus on short-term projects he or she can control seems short-sighted. The person who perceives her- or himself as maintaining high standards comes across as overly critical. Common assessment tools include: • Written tests that reveal critical thinking skills 52 Nurse Leader
• Behavioral interviewing that asks probing questions into how one goes about making decisions • 360-degree surveys that gather feedback from managers, peers, direct reports, and others • Executive assessment centers for more-senior leaders that provide a well-rounded picture of leadership capability through “day-in-the-life” simulations When choosing an assessment instrument, it’s absolutely essential that you define in advance how the results will be used, match assessment results against the success profile you created, and openly communicate the process so that it is perceived as fair. Properly completed assessments will clearly show where you need to focus development efforts and which individuals don’t have what it takes to succeed in a leadership role.
Step 4: Training for Gain Once leadership skill gaps have been identified, design a curriculum to close those gaps. Few people are naturalborn leaders; most learn leadership behavior—good and bad—from others. And that’s how your people can learn leadership skills—by instructive role modeling. A blended learning approach that integrates classroom learning, exercises, simulations, role-playing, and even online interactivity is best. Assigned mentors and coaches help fledgling and senior leaders learn how to get through rough patches unscathed. The University of Pittsburgh Medical Center (UPMC) matches its leadership development participants with working projects. The value created through these projects has approached $500,000 in real savings over 2 years, with potential long-term saving opportunities estimated in excess of $38 million.7 UPMC’s success has evolved into the Health Care Leadership Academy,8 a national leadership development program in partnership with Development Dimensions International that targets frontline, operational, and strategic leaders for intense 1- or 2-week development training sessions. The academy will graduate its third group of leaders this spring. Regardless of curriculum approach, administrators must ensure that training goals are clear and meaningful for all participants. Whenever possible, link the training that supervisors and direct reports receive, such as empowerment training and team building.
Step 5: Sustaining Momentum Injecting a degree of tension into learning ensures that training sticks with your leaders and they use their newfound skills on the job. For instance, many organizations make leadership development training mandatory and back it up with consequences for those who miss sessions. Others go much further by measuring how leaders’ behaviors have improved after training. You can sustain momentum even more through additional classroom learning, online/situational learning, project work, and temporary “stretch” assignments in addition to proactive mentoring, coaching, and role modeling. And you can extend the length of your pipeline by training December 2004
your current leaders in how to identify nurses with the potential to assume future leadership roles.
OVERCOMING RESISTANCE Although few would argue that ensuring a dependable nurse leadership pipeline is a good idea, the action must come from within the organization. The plan must be measurable with metrics linked to the organization’s strategic priorities. It must be endorsed and actively supported by an influential management sponsor. And it must be sold to and embraced by the leadership ranks and staff. There’s little question that you will receive resistance. Both management and staff will contend that there is precious little time and that resources are scarce to invest in a leadership pipeline. Your plan may be perceived as making little difference or as just another “program of the month.” And it requires a significant shift in perception of the organization’s hiring, orientation, promotion, and performance evaluation systems—systems that have been in place for decades. But the results for the organizations that have taken the time, invested the resources, and bought into the behavior-based competency model for building a leadership pipeline show a significant return on their investment, with reduced turnover, higher levels of staff engagement, and improved job performance. That’s strategic value any senior manager can understand. References 1. Joint Commission on Accreditation of Healthcare Organizations. 2005 national patient safety goals. Oakbrook Terrace (IL): Joint Commission on Accreditation of Healthcare Organizations; 2004. 2. Joint Commission on Accreditation of Healthcare Organizations. Leadership and performance improvement standards. Oakbrook Terrace (IL): Joint Commission on Accreditation of Healthcare Organizations; 2004. 3. American Hospital Association. 4. Buerhaus P, Staiger D, Auerbach D. Implications of an aging registered nurse workforce. JAMA 2000;283:2948-54. 5. Development Dimensions International. 2003-2004 Leadership forecast. Pittsburgh: Development Dimensions International; 2003. 6. American Hospital Association’s Commission on Workforce for Hospitals and Health Systems. In our hands: how hospital leaders can build a thriving workforce. Chicago: American Hospital Association’s Commission on Workforce for Hospitals and Health Systems; 2002. p. 33. 7. Wolf G, Bradle J, Nelson G. Bridging the strategic leadership gap: a model program for transformational change. J Nurs Admin. In press. 8. Health Care Leadership Academy [Home page]. Available at: www.hcleadershipacademy.org.
Lauren Arnold, PhD, RN, is a nurse executive for the Advisory Board Company. Greg Nelson is vice president of the Health Care Practice Group for Development Dimensions International in Pittsburgh. He can be reached at [email protected]. 1541-4612/2004/$ see front matter Copyright 2004 by Elsevier Inc. doi:10.1016/j.mnl.2004.10.003
December 2004
Nurse Leader 53