AHRQ Views

Blog posts from AHRQ leaders

Richard Ricciardi, Ph.D., N.P., Senior Nursing Advisor, AHRQLeading from the middle describes the actions of individuals who are able to influence those in a position higher or lower than themselves. Few others in the health care field fit this description better than frontline nurses, who serve as the link between upper management and support staff. Embracing this role can help nurses create positive change that makes care safer for patients.

Leading is often considered a soft skill, and in fast-paced clinical settings, soft skills are often overlooked and undervalued. AHRQ’s research, however, has demonstrated that soft skills are a critical component to making care safer. Although senior leaders may decide that a new checklist or protocol should be used, it’s the leadership on the front lines of care that ensures the checklist or protocol is implemented effectively. Simply put, when frontline nurses are empowered and take on a leadership role, patient care improves and job satisfaction increases.

It’s critical that all members of the clinical team—nurses, doctors, and support staff—understand the goals for patient care and work together to create positive change that delivers the best possible outcome. AHRQ has long recognized the importance of strengthening a culture seeking to create positive change, developing tools and resources to help those on the frontlines of care put this concept into practice.

For example, our work to develop and implement the Comprehensive Unit-based Safety Program (CUSP) demonstrates that empowering frontline staff can significantly improve care. CUSP is a proven method for making care safer that combines improvement in safety culture, teamwork, and communications with a checklist of evidence-based practices. The CUSP toolkit contains many resources, including guidance to help frontline nurses take on a leading role that empowers them to create positive change. Nurse Theresa Hicks used the CUSP method to lead her rural Texas hospital to zero central-line bloodstream infections. She says of CUSP, "Historically frontline caregivers, especially nurses, have not been included in safety programs. The CUSP turns that model on its head, and it empowers the frontline caregiver to make a difference."

In empowering nurses to play a leading role, TeamSTEPPS® helps to improve the communication and soft skills that nurses need to create positive change. This evidence-based teamwork curriculum can help clinical teams in a variety of settings be more efficient and respond quickly and effectively to the dynamic nature of patient care.

TeamSTEPPS was originally designed for hospital-based teams. Building on that success, we’ve also developed TeamSTEPPS training materials specific for long-term care facilities and for office-based care settings. Using these resources, nurses in all these settings of care can strengthen the soft skills they need to take on a leadership role and create positive change.

AHRQ also has many other resources to support nurses in leadership roles, including Web-based continuing education that’s available to nurses at no charge. A full catalogue of topics is available.

Creating positive change in the health care system is necessary to make care safer, and it requires frontline nurses leading from the middle. This is why the American Nurses Association’s (ANA) 2016 campaign "Culture of Safety" is so important.  By leading from the middle, nurses play a critical role in improving the safety and efficiency of health care.  As an Agency, AHRQ is committed to giving nurses and other frontline clinicians the tools they need to bring the highest quality care possible to their patients every day.

Page last reviewed August 2016
Page originally created August 2016
Internet Citation: Create Positive Change—Lead From the Middle. Content last reviewed August 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/blog/ahrqviews/create-positive-change.html