Statistics from Altmetric.com
Bob Dent, DNP, MBA, RN, NEA-BC, CENP, FACHE, FAAN, FAONL
Bob Dent is vice-president of patient care and chief nursing officer for three hospitals within Emory Healthcare. He maintains academic appointments with Emory University, Texas Tech University Health Sciences Center, the University of Texas of the Permian Basin. Dr Dent is a past president of the American Organization for Nursing Leadership (formerly AONE).
Dr Dent’s career spans more than 30 years in such roles as nursing assistant, LVN, RN, assistant director of nursing, director of nursing, licensed nursing home administrator, CNO, dean of health sciences at a community college, COO and system CNO.
Dr Dent is the recipient of Modern Healthcare’s Class of 2006 Up and Comers in Healthcare Administration; Texas Organization of Nurse Executives 2013 Excellence in Leadership Award; Texas Tech University Health Sciences Center Distinguished Alumni 2014; and 2016 Richard Hader Visionary Leader Award.
Over the course of his career, Dr Dent combined his expertise in nursing and leadership to author four books, book chapters, many journal articles and presentations related to culture, improving workplace environments, interprofessional collaboration and nurse staffing.
What are the key leadership messages you want to get out to the BMJ Leader readership?
Leadership is important during all change, small and large, but it is especially crucial during dynamic, massive and multifaceted change—such as the changes prompted by the coronavirus pandemic (COVID-19). It is essential for leaders to recognise the state that we are in, understand what the front-line staff needs and assure they have it, and embrace the importance of visibility, communication and transparency.
Everything has changed and will continue to change. As we are going through these change management cycles, it is essential to understand people’s behaviours and why they might be reacting the way that they are reacting—whether it is anger, frustration or even apathy. In any change management cycle there are tough times, a valley of despair if you will. How long we stay in the valley of despair depends on leadership, especially their visibility and communication. For example, when we started to treat patients with COVID-19 back in March, my leadership team was all working 14+ hour days, 7 days a week, so that we could be there with the front-line staff and understand how they were feeling and what they needed. We were out there making sure that we had the right numbers of people caring for the patients, that our front-line staff had everything they needed to provide the same loving care, and that our staff, patients and visitors were safe. Although we cut back on visitors, we endeavoured to maintain contact between the patient and their family members and assure that no one was left behind or alone, especially in those dying moments.
We are all learning, as a country and as a world. The more we learn, we can hone in on the things that enable excellent patient care and a great work environment for our people. Throughout the learning process it is important to be transparent that we do not have all the answers, while working to make decisions based on the best information possible. I have found an experienced network of colleagues and being actively involved in our professional organisations to be invaluable in this process.
Tell us a little bit about your leadership role and how it is changing as a result of the pandemic?
My formal role is the vice-president and chief nursing officer (CNO) for three hospitals within Emory Healthcare: Emory Decatur Hospital, Emory Hillandale Hospital and Emory Long-Term Acute Care Hospital. In general, my role involves advocating and influencing the things that happen within nursing services and my operating unit, as well as the larger system.
As a result of the pandemic, certain aspects of my role have expanded or intensified. For example, I coach and mentor relatively new nurse leaders in my organisation, as well as new nurse leaders in other organisations through the American Organization for Nursing Leadership, including three hospital CNOs. However, since COVID-19 hit, several other nurse leaders have reached out. I’ve gotten phone calls from people from New York to California to say, hey, how are you dealing with this? It has become increasingly important for nurse leaders across the country to stay connected and be there for one another.
COVID-19 has also increased the importance of my role in advocating for nurses and engaging in effective interprofessional collaboration. Collaboration is happening in real time every day, minute to minute—it has been that dynamic.
What events in your past experience are most informing your leadership in this pandemic?
This experience is unprecedented. No one in this age or time has ever really experienced what we are experiencing right now, and we are not out of the woods yet. In many ways, the pandemic tests our organisational foundation—our leadership, our teams, the invisible architecture of our culture, the strength of our core values and our ability to engage in change management. Although it is not precisely the same, I’ve been able to draw from previous experiences building a culture of ownership and implementing change. For example, I can see frustration and recognise it as an unmet need, which I need to help address if I can, or if I can’t, I have to tell them I hear what you’re asking, but we just can’t do that right now.
What are you finding the biggest challenges?
The biggest challenge is to help our front-line teams keep up with all the changes. There has been so much change; today, we have to do this, and tomorrow it is something else. It is a challenge to continuously be nimble, dynamic and responsive to staff needs. To do so, we have employed a lot of lean methodologies, including the tiered huddle process.1
We are also engaging in a lot of strategic planning to manage what we are currently experiencing and prepare for that next step, which raises concerns about staffing. Staffing continues to be a concern all across the country, which COVID-19 has exacerbated. The acuity level of patients with COVID-19 is high. For example, proning patients with COVID-19 in the intensive care unit takes a team of six to eight people, whereas usually, it could be one or two. It also takes more time to don and doff personal protective equipment going in out of rooms. Staff are also getting sick themselves. On any given day within my three hospitals, we have had multiple people out sick with COVID-19. I was out with COVID-19 myself in early April, but fortunately, I had a mild to moderate case of it. It is important that everyone understands how serious COVID-19 is and that we can’t let our guards down. The combination of increased workload, vigilance and grief is incredibly hard on the staff. Some staff have even relocated themselves or their children with other family members, to avoid the potential of infecting loved ones. Initially, these sacrifices were nationally recognised, and healthcare workers were celebrated as heroes. The sacrifices have not ended, but the national support seems to be waning.
Any particular surprises?
A positive surprise was just how nimble we could be as a healthcare system. It has been remarkable how fast we have been able to make some changes. Pre-COVID-19 changes typically took months—meetings happen, we talk about an idea, a month later we pick up on it, then maybe there is progress, and then a month later there may be a decision. During COVID-19, people are making decisions within hours and coming up with innovative protocols or new best practices.
Another positive surprise is just how collaborative we can be as an interprofessional team. It is not only one discipline or another but how we come together. For example, there has been a lot of recognition from the medical staff and the senior leadership team that the wonderful outcomes we’ve had within Emory are because of the nurses. The nurses also recognise it because of our medical staff, respiratory therapists and other team members. It has been awesome to see the appreciation for one another among our interprofessional teams and how well we have worked together to make changes rapidly.
In terms of a negative, I am not sure it is necessarily a surprise, but at least a consequence of COVID-19 is widespread hospital financial issues. For hospitals, there is a huge economic consequence to the pandemic, both in terms of increased expenses (staff compensation, equipment) and decreased revenue (shutting down elective procedures—which are the economic engine of a hospital). Some organisations have opted to do across the board pay cuts indefinitely; others have had furloughs or layoffs. The financial crunch is especially hard on rural facilities, many of which may not make it through this crisis.2 We need the country to come together to overcome these challenges.
Are you seeing any behaviours from colleagues that encourage or inspire you?
I have been really impressed by the collaboration from everyone in my organisation, especially our system chief nurse executive and our chief executive officer for Emory Healthcare. They act with a sense of urgency but have this executive presence where nothing shakes them, it is almost calming when you engage with them in the different meetings. They lead most of the incident command centres and our tier five huddles. They really want to know if there is a problem and pull the right teams together to address it promptly. I have also been impressed by the accessibility and engagement of the other CNOs within Emory Healthcare. We are texting on a regular basis and on Zoom calls daily. Whenever there is an issue in any one of our hospitals, we are reaching out and helping each other get through whatever immediate, urgent need there might be.
How are you maintaining kindness and compassion?
Being in the Gemba, where the work is getting done, to understand the challenges that the front-line workers face. I love to be with the people, and so I am regularly rounding. I have always been an early person, so I usually arrive at the hospital between 04:00 and 05:00 hours. I always go through the emergency department and visit with our medical staff and nursing staff to make sure they have what they need. When we first started treating patients with COVID-19, I went to most codes to be there with the staff and support them.
Are there any ideas or readings that you find helpful, for inspiration and support, which you would recommend to others?
I often draw on the work of Florence Nightingale for inspiration, reflecting on what she was dealing with during the Crimean War and how she was trying to change the healthcare system. Interestingly, in 1870 Florence wrote in her diary, ‘It will take 150 years for the world to see the kind of nursing I envision.’ Here we are 150 years later in 2020 facing a worldwide pandemic, and nursing has risen to the call. I am also in a book club, which is reading How to be an Antiracist.3 I have been doing a lot of reading on the topic to better understand what we can do to help with our systems, policies and procedures to address these issues locally and across the country.
I also recommend a monthly ‘sharpen the saw’ day of reflection. I use the day to reflect on how I am doing with my work, within my profession and in my own life—with my family and my faith. I reflect on the principles of building a culture of ownership in healthcare,4 and the principles in the heart of a nurse leader, with the associated 12 core action values.5 I then consider what I could do over the next 1–3 months to make sure that I am in tune and doing all that I can in those areas. As we are still in the crisis, there is less time to sit back and reflect. However, that reflection will be essential to learn from this experience and use it to improve healthcare within the communities we serve.
What are you looking for from your leaders?
The same things we talked about earlier, visibility, communication and transparency. I need them to be emotionally positive, self-empowered and fully engaged in the work. This includes being in the Gemba: for senior leaders that is about 10% of their time, for specialty directors about 25%, and for unit directors, those who manage at the front line, almost 50% of their time. I challenge my leaders to really look at how they are spending their day and to assure they are spending sufficient time with the front-line staff, understanding the workflow processes, helping to mitigate any issues, being compassionate and empathetic, and assuring that we are delivering the best we can in our patient care and experience.
Twitter @bobdent, @M_M_Luciano
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.