Dr. Cole Edmonson’s Culture of Engagement at Texas Health Presbyterian

Dr. Cole Edmonson, chief nursing officer at Texas Health Presbyterian Hospital Dallas, found that putting nurse manager leadership theory into practice created benefits that ripple throughout the hospital

Dr. Cole Edmonson has cultivated a close-knit team of nurse managers, a result of low turnover at the organization.

Nurse managers are extremely important to the mission of the organization, according Dr. Cole Edmonson, chief nursing officer at Texas Health Presbyterian Hospital Dallas, one of the largest facilities in the Texas Health Resources system of twenty-nine hospitals. As clinical leaders, nurse managers connect the entire interprofessional team to the patients and their families, and they have a great impact on patient outcomes and hospital performance. “It’s also one of the highest-pressure jobs in healthcare,” Edmonson says.

That said, Edmonson says that hospitals that devise policies, training, and a culture that allow nurse managers to thrive will be well positioned to achieve high-quality care and create a workplace with high employee engagement. The 875-bed Dallas hospital realized notable gains in those areas after putting Dr. Barbara Mackoff’s Nurse Management Engagement Theory into practice. The hospital’s employee engagement ratings have consistently ranked in the 98th and 99th percentile for the past four years after the program kicked into high gear. Surveys measuring nurse engagement and job satisfaction also got a big boost. In fact, that number jumped from 55th percentile to 98th percentile in just over four years. Today, controllable nurse manager turnover is virtually unheard of at Texas Health Dallas, Edmonson says. This is reflected in the number one reason nurse managers leave their position: getting a promotion. Edmonson says this is related to the strong succession planning model in nursing and leadership development at the facility.

Dr. Cole Edmonson, Texas Health Presbyterian Hospital Dallas Portrait by YoungDoo M. Carey

Edmonson spearheaded the initiative that reformed several aspects of the nurse manager role. Nurse managers scopes and spans were right-sized, and nurse managers were given guaranteed uninterrupted time each day to spend on the floor with patients and staff, allowed more ability to effect change in patient treatment, provided more opportunities to influence institutional policies, and given better support to deal with the stresses of the job.
Edmonson believes other healthcare organizations can learn from these practices and policies that if widely implemented would improve healthcare nationwide.

The roots of the initiative came from research by Mackoff, a professor, psychologist, and researcher. Mackoff studied the habits, attitudes, and backgrounds of a couple dozen high-performing nurse managers. She wanted to know what made them perform well and what kept them enthused. The key findings were that they managed to remain engaged with clinical activities, received quality leadership training based on an emotional mastery curriculum, and felt that they were building a legacy of the next generation of nurses and leaders. These high-performing nurse leaders also exhibited a sense of being mission-focused, which she says always came from an affirming, appreciative perspective, and had true boundary clarity. Mackoff developed the nurse manager engagement theory based on this research.

Intrigued by the findings, Edmonson reached out to Mackoff seven years ago to help develop a plan to put the theory into practice at Texas Health Dallas. The first pillar of the plan was to build in protected rounding time (The Sacred Sixty) into every nurse manager’s schedule. “We set aside one hour per day,” Edmonson says. “That is protected, sacred time: no meetings, phone calls, or emails during that time—except for urgent issues.” It gives nurse managers devoted time to stay connected to what drew them to the profession in the first place: patients. This measure has proven its value over time, Edmonson says, as it has helped nurse managers to enrich their relationships with nurses they lead, physicians, and other professionals including technicians and clinical managers. Having this line of site directly to patients provides the opportunity to create relationships through an authentic, caring presence with patients, families, and their nurse colleagues.

The daily protected rounds enable nurse managers to regularly share their expertise with other healthcare professionals, see firsthand how staffing and other management decisions are impacting their patients and colleagues, keep tabs on new treatment options, witness patient outcomes, and understand what is impacting the morale of nurses. This produces, Edmonson says, more engaged and better leaders with a stronger sense of professional fulfillment and attunement. In fact, the strategy proved so valuable that senior leaders decided to double the daily protected rounding time to two hours and roll the concept out to all of the hospital’s leaders, as Sacred Sixty Plus.

Edmonson also believes that reflection is a crucial part of every leader’s development. Putting this into practice means that every nurse manager is now eligible to spend one day per month working from home to reflect on their own leadership characteristics, practice mindfulness, reflect on where their unit is and how it contributes to the success of the organization, and strengthen their leadership by learning new skills.

Another key component of the engagement theory plan was to enshrine the emotional mastery concepts into monthly leadership training. One of the keys to this approach is understanding one’s moral code and ethical framework to glean insight into situations that cause moral distress. Edmonson’s doctoral work focused on how nurse leaders uniquely experience moral distress. Situations are never simple, but Edmonson says that leaders must be encouraged to find an appropriate way to voice and act on their moral concerns.

Moral distress for nurse managers comes in many forms: clinical, financial, human capital, and quality. For example, nurse managers are expected to maintain productivity standards for their units. This can create moral distress when there is a perceived conflict between the benchmarks and the practicality of staffing. Organizations must provide a safe space for concerns to be elevated and resolved.
Building a culture that supports crucial conversations, safe disagreement, and effective resolutions decreases moral distress and improves outcomes. Having a safe space and respectful conversations reduces moral residue that can create burnout, turnover, and fatigue in leaders.

To broaden the support base for nurse managers, a peer-led, peer coached group of nurse managers meets monthly, which gives them an opportunity to connect with and learn from others facing similar challenges. In addition, that group has been participating in a year of SelfCare,  a structured program by nurse recruitment expert LeAnn Thieman that focuses on their own well-being. Leaders who model healthy behaviors and lifestyles can assist others in doing the same by their example. Early results indicate a 15 percent increase in participants balancing their lives with exercise after the program, which is just one measurement of success. “Changing lives for the better is what we do as nurses,” Edmonson says. “So why not care for ourselves with the same passion, dedication, and love we give to our patients and families?”

In a separate development, the health system is on a journey to become a high-reliability organization. Over the past three years, leadership has worked to build a culture that strives to put all healthcare workers on an equal basis when it comes to serving patient needs. Employees throughout the organization use error-prevention tools to advance quality and safety and to voice concerns they might have about a diagnosis or treatment plan. “People feel safe speaking up to people who have real or perceived higher authority or are in a different position,” Edmonson says. “This creates circles of care around the patient, flattening the traditional hierarchies that can exist in healthcare. Everyone strives to provide their expertise at the right time in patient care to get the best outcome for the patient, the family, and the community. It creates a community of collaborators, not just colleagues.”

In turn, the nurse manager engagement program has been able to thrive in this environment because of the intentional design, inherent support, and respect it fosters for all healthcare professionals. This culture took years of building but has paid off in many ways, Edmonson says, including improved resilience. “Resilience is about how fast you can bounce back from a negative event or negative situation,” Edmonson says. Rather than seeking to pass the buck and assign blame, the culture is more likely to yield people attuned to learning when something goes wrong, he says. It makes for more positive, respectful cultures of engagement for nurse managers—and the entire organization. “If I could remove the title of nurse manager from healthcare, I would, as I believe these are nurse leaders,” he says. “We manage processes, but we lead people and these leaders need unique support if they and the organization are to flourish.”


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