Bill Klaproth (Host): This is a special episode of Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership, recorded live at the AONL 2024 Conference. I'm Bill Klaproth, as we talk about Empowering Nurse Leaders With Ethics, Education, and Professional Development. With me is Aliza Narva, Director of Ethics at the Hospital of the University of Pennsylvania. We also have Christina Salemo. She is the Advanced Senior Lecturer and Vice Chair of the Biobehavioral Health Services Department at the University of Pennsylvania School of Nursing. And we have Meghan Fitzpatrick, Advanced Senior Lecturer and Associate Program Director at the University of Pennsylvania School of Nursing.

Thank you for stopping by our podcast booth, ladies. We appreciate it. Meghan, welcome.

Meghan Fitzpatrick: Thanks for having us.

Host: Yeah, this is great. Christina, thank you for being here.

Christina Salemo: So good to be here.

Host: Yeah. Aliza, thank you for your time.

Aliza Narva: Bill, thank you. It's a thrill.

Host: No, thank you. I just want to say thank you, Aliza. This is great. And we're excited to hear about your session. So, Aliza, let me start with you. Can you tell us about your session and why you wanted to address ethics education?

Aliza Narva: Absolutely. So, we are here today to present our novel Leadership and Ethics Fellowship that we created, where we basically spend a year with a group of frontline nurse leaders, growing their leadership skills, growing their ethical competence, and really giving them the tools to go back to their clinical environments and help to relieve the moral distress of their teams, and help their teams deal with the kinds of everyday ethical issues that they're seeing in clinical care.

Sometimes when we think about ethics, we think about bioethics, we think about sort of the big ethical dilemmas that we see on television or in movies, right? Declarations of brain death or things like withdrawing life-sustaining therapy at the end of life. But we know that nurses specifically deal with sort of these smaller issues every day in clinical care that we don't necessarily think of as ethical issues. And when you're not realizing that something is an ethical issue or has ethical implications, you're probably not using an ethical framework to think about what the right thing is to do. Nursing ethics is really about relationships and making sure that we are keeping patients and families at the center of care. And so, we wanted to make sure that these pivotal nurse leaders have everything they need to support their teams as they provide care in busy clinical environments.

And on top of that, we wanted to bring in a lot of leadership expertise, because there's a lot of overlap actually between leadership skills and everyday ethics. And so, we created this partnership with our faculty colleagues at the School of Nursing and myself and Erin Marturano, who also works at the hospital with me to really blend the two disciplines together in a way that would provide a set of really holistic skills.

Host: So, it sounds like these leadership types of skills, ethics are not ordinarily taught, that's why we need this type of education. Is that right?

Aliza Narva: Yeah. We know that nurse leaders do not get enough formalized leadership or ethics education, and so we're basically just investing in their success by making sure that they have them as they move forward. Especially at this time when we're coming out of the pandemic, we know that there's a lot of burnout, we know there's a lot of moral distress. And we're looking to keep people in the clinical environment. We want to hold on to nurses, especially nurses who have leadership expertise, who have spent a lot of time at the bedside. And this is a way to really invest in them in a way that has serious, good financial implications for healthcare organizations.

Host: So, this not only benefits them, but also better patient outcomes and I would imagine better ROI for the hospital. Would that be a fair statement?

Aliza Narva: Absolutely. We know that things like moral distress and burnout can cause the average hospital to lose between $3 million and $6 million a year. So, this really is something that is intended to improve the well-being of nurses at every level and keep them connected to patient care and the joy of the job.

Host: So Meghan, tell us, how did you put this together? You saw the need, you know the problem. How did you address this? How did you tackle this?

Meghan Fitzpatrick: Yeah. So, it was really multifaceted. So, we all have experience as frontline nurse leaders. So, we've been in their shoes and we know the need and Aliza has done a really good job of sort of elaborating on the need. And so, I think where it started was our relationships with one another. We saw that Aliza and Erin, who worked on this project with us were seeing the stress and burnout and moral distress on the front lines with the nurse leaders. And we're looking to develop this curriculum.

Christina and I have expertise in the academic setting of developing a course curriculum. And so, we came together and we said, you know, really, how can we make this most beneficial to these frontline leaders to empower them, but also give them a forum to meet other nurse leaders to express some of their concerns about their roles and their staff. And, you know, at the end of the day, give them a really usable skill set.

Host: Yeah, that makes sense. So Christina, for someone that wants to duplicate what you did or follow in your footsteps, if I called you on the phone and said, "I heard this podcast, I love what you guys are doing. How do I do this?" How does someone get started with this?

Christina Salemo: Sure. Well, please call us. We would be happy to hear from anyone. But, you know, I think something that was really important to us as we were putting this together was we wanted to have a program that was really structured and really had a solid framework to build upon. And so, we looked to resources that were out there. We looked to the AONL Nurse Leader Competencies. We looked at the ANA Code of Ethics. We looked at the Future of Nursing 2020-2030 Report. And we pulled everything together to inform our curriculum and to inform the different topics we were going to cover throughout the year. So, I think a formalized structure really helped us to stay on track and to have a good plan at the outset.

It was also really important to us to measure our success. And so, there were a number of different pre-surveys that we sent out about leadership, about ethical confidence, about moral distress that we tracked throughout the program so we could really monitor how our program was impacting the frontline nurses leaders and if it was impacting them in the way that we hoped it would.

Host: Yeah, that makes sense. So, what else should we know, Christina? What else should we know about this program, as well, for someone listening to this, for wanting to start and do this program?

Christina Salemo: Absolutely. I think another factor that we really incorporated into our planning was what the needs were for our organization. And I think this is really important for other organizations who are thinking about implementing in their own sites. You have to know what's important and what your organization really wants to get out of it so that you have the buy-in that you need from the organization itself, and that it's really resonating with the leaders who are going through the program. So, I think really understanding where you are as an organization and how supporting your frontline nurse leaders can help your organization is a really good first step.

Host: So, Aliza, as the Director of Ethics, what is the key takeaway for someone listening to this to remember, from your point of view? So, we're doing this in the middle of a thunderstorm, that's what that is. So, yes.

Aliza Narva: You know, I think there's a couple of things. Part of it is that we need to continue to invest in professional development for our nurse leaders. They want it, they need it, and actually their teams benefit from it, right? I think that's really important.

I think the other thing that we haven't talked about as much, but that is really important, is that a lot of this is about communication. And so, communication can go into a lot of different buckets, but it definitely goes in the leadership bucket, and it definitely goes in the clinical ethics bucket. And if we are preparing these folks with good communication skills, and showing them how to engage their curiosity about the other stakeholders in their environment, it's going to positively impact not only their professional relationships in the clinical setting, but the way that patients receive care. And I think that's really important, especially for nurses.

And so, I think we're excited about what we can do as we move forward. We know that nurses need this. We know that if we give nurse leaders communication training, and teach them about clinical ethics, it reduces their moral distress, right? It helps them feel like more confident leaders. And I think that's really compelling for us, and we're looking forward to seeing how we can continue to really grow ethically-confident leaders in the executive space for nurses.

Host: And Christina, what have the results been so far, the results of your efforts?

Christina Salemo: They've been really exciting. So, what we found in the course of our fellowship is that the fellows that go through have an increase in their authentic leadership behaviors, they have an increase in their ethical confidence, and they have a decrease in their moral distress, which was exactly what we were hoping to find. So, we're really excited to continue to look at that.

We also really want to look at nursing turnover of these leaders. Because I think that could have really wide-reaching implications. And overall, the feedback has been so positive. I think that this program really resonates with nurse leaders and really gives them a professional development opportunity that they want and don't otherwise get.

Host: Yeah. Meghan, were there any challenges or things that you learned along the way that surprised you with this program?

Meghan Fitzpatrick: You know, I think something that's really interesting and we knew a little bit going in is that sometimes the concepts of ethics and leadership can be really vague. And so, what we found was that we really needed to define those terms for people. And we were able to do a lot of education on leadership for nurses that were already in formal leadership roles. We found that they hadn't had a lot of education in that area. And it's kind of one of those situations where you don't know what you don't know until you're learning it. And I think we received really great feedback on that. We actually increased the amount of leadership content for cohort two of our fellows.

And so, that's something that's near and dear to my heart. I teach leadership in my role. And so, I think that was a big takeaway for me. I think use the terms ethics and leadership as sort of almost buzzwords. And so, when we really got into the nitty-gritty and defined it for people, it changed everything for them. And I think it was a really impactful experience for them, but also us as educators, to kind of learn that, you know, we need to do a better job at the start of nursing education, probably in bachelor's programs to really define these things for nurses.

Host: Yeah. Like you say, you don't know what you don't know. And I would imagine people might be afraid to ask questions too, like we all are. "Well, I don't want to ask that question. I'll look like I dummy, like I don't know it." So yeah, that's probably interesting to find that some people that there wasn't a big distinction or knowledge of the difference between leadership and ethics or what each one of those meant. Anything else that found that was interesting or surprised you?

Meghan Fitzpatrick: You know, It's been a theme of our discussion today, but it's something that is also very important to mention. I think we really have to do everything we can to support frontline nurse leaders. We support frontline staff really well in a lot of organizations. But the frontline nurse leaders, meaning those nurse managers, assistant nurse managers, unit-based educators, they're not always getting a lot of professional development and support themselves. And they're doing everything they can to educate and empower their staff. And so, we, you know, see it as our role to educate and empower them.

Host: Yeah. And Aliza, a question for you. Anything that has surprised you at all from your position or role?

Aliza Narva: Something that's been really rewarding is to see in the cohort how the fellows, how much they value spending time together and how safe they sort of feel as a group. You know, these are folks who are in similar positions but in really different practice settings. And so, it's been an opportunity for them to come together and form a bunch of new relationships and new networks and get new perspectives on the specific challenges of their clinical environments. And so, that has been really lovely.

You know, something that we were doing initially was occasional reflective writing to help them sort of digest the content and think about how to walk the walk with it in their practice, and that was so popular that we ended up increasing the amount of reflective writing. I had sort of anticipated that they wouldn't like it. But in fact, they loved it so much that we added more. And they really want to talk about their experiences. You know, I don't know that we have traditionally created enough places for nurse leaders to talk about what they're going through as nurse leaders. And so, you know, Meghan and I both did the AONL Nurse Manager Fellowship, and I think that experience was helpful as we built this. And that experience is really about a cohorted group of folks coming together to talk through the challenges of these roles, which are really hard, especially in a post-COVID landscape.

Host: Absolutely. Christina, any surprises from your end?

Christina Salemo: You know, I think the thing that surprised me most and that we saw increasing value in as we went through this program was the ability for nurse leaders, again, to share their experiences, but it let them apply the skills that we were teaching them. And so, we wove in a lot of space for them to share situations that were happening on their unit. And what we saw was the leadership and ethical management principles that we had just lectured about being employed as they were giving advice to their peers. And so, I think that peer support, as we've mentioned, is so important, but also lets us as educators see that what we were teaching them was then being applied to how they looked at different situations.

Host: Yeah, that had to be rewarding. How long does the training take, or how does that work?

Meghan Fitzpatrick: So, the fellowship is one year long. So, they're coming to monthly sessions for three to four hours each month. And then, they're also, in addition to that education, participating in a mediation intensive, where they're doing simulation training around conflict resolution.

Host: Okay, interesting. Well, I want to thank you all for your time today. This has been great. I'd love to get some wrap up thoughts from each of you. Aliza, let me start with you. Anything you want to add?

Aliza Narva: One thing I want to mention is just, you know, Meghan just discussed or mentioned the mediation-intensive, and that is actually something that is increasingly being used in healthcare, is using mediator tools to think about how we talk to folks in our clinical settings. And actually, most ethical issues come down to miscommunication. So, we really focused on building those skills in this group so that they feel confident in asking more questions, in slowing down before they make a decision, in making sure they're getting all the right stakeholders in a situation where there is a complicated problem in the clinical setting. And so, that is something that they have really enjoyed and has been very satisfying. That piece of the programming comes to us from Dr. Autumn Fiester at the Perelman School of Medicine at Penn. But it's a really critical part and it's really fun, as Christina was saying, to watch them use those skills in real time or, you know, they come back to us and say like, "Oh, I used those mediation skills to help a family that was feeling distressed or to resolve an issue between a nurse and a physician."

Host: So, I would think in leadership, teaching communication skills is one of the things, as a leader, you're supposed to know how to communicate, but often not. As you say, most ethical problems result from communication issues.

Aliza Narva: Absolutely.

Host: Yeah, that's really interesting. Christina, final thoughts from you?

Christina Salemo: I am so glad you said that, because I think something else that we may have assumed even going into this was that people had these skills already and they were using them every day because they practice leadership every day. And I think what we found through this program is there is such value in providing formalized education to nurse leaders because it supports their confidence and being able to do their job and to lead their teams, and also is really fulfilling to say we're investing in you to make you the best you can be.

Host: Absolutely. Well said. And Meghan, how about you? Final thoughts?

Meghan Fitzpatrick: So, I think I'd just like to highlight the partnership again. I think the partnership between the clinicians and those of us in the academic setting is really valuable. I think that there is so much formal education, and that's what we typically do. We teach in bachelor's programs, master's programs, doctoral programs. But that informal education is just as important to nurses in the clinical setting, that professional development. And so, I think we were really fortunate to partner together, and I think this is just the beginning of it.

Host: Yeah, well said. Well, thank you all for your time today. This has been great. We really appreciate it. Thank you.

Meghan Fitzpatrick: Thank Thank you.

Host: Great job.

Aliza Narva: Thank you so much for having us, Bill. One question for you is, can I get a picture of us in conversation that I can send to my husband that he can see that we're like doing serious business?

Host: Yeah, serious business podcasting. Yes, we will definitely get that picture done for you. a problem. Oh, look at that. Christina's taking it right now in process. Thank you. Love it. Once again, that is Aliza Narva. We also have Christina Salemo and Meghan Fitzpatrick. Thank you again for your time. I really appreciate it. And for more information, please visit aonl.org.

And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you, just like this one. This is Today in Nursing Leadership. Thanks for listening.