Finding your strength in a time of crisis: Reflections from an oncology nurse leader

Abstract

Dr. Charissa Cordon has two decades of experience in healthcare, as a nurse, educator, and leader. She was recently appointed to the role of Associate Vice President for Practice and Academics at William Osler Health System. She has held other senior leadership roles such as Director of Professional Practice and Clinical Resource Team, Chief of Nursing Practice, and Chief of Interprofessional Practice in Oncology. With a wealth of experience as a transformational change leader in nursing and professional practice, she has led many initiatives at the local, provincial, and national levels. In her Keynote Address at the 2023 CANO/ACIO Conference, Charissa shared her personal reflections on her life experiences that shaped her values and principles as a leader, and provided examples of how she draws on her inner strength to lead during difficult and challenging times and shine a bright light to those around her.

Today, as we continue with our post-pandemic recovery efforts, nurses and nurse leaders must continue to work together to support our young nurses who are new to the profession. We also need to continue to lift each other up, support each other, support our new leaders, and shine a bright light to those around us. Our strength as nurses and leaders, during a time of crisis comes from within us, individually from each of us, and together, as a collective whole.

INTRODUCTION

One of the best definitions on leadership that I have encountered appeared in an article I read recently on Forbes – “Leadership is a process of social influence, which maximizes the efforts of others, towards the achievement of a goal” (Kruse, 2015, para. 1). To me, this is such an impactful statement, as it stipulates many things: (1) that one does not have to be in a formal leadership role to be influential; (2) that leadership involves collaboration and supporting others to be the best version of themselves, individually and as a group; (3) there needs to be a common goal or a vision to be striving toward; and (4) you need to achieve and in order to do that, there needs to be a clear strategy on how to get there, and how to measure your success as a group.

Over the past four years, I have been reflecting on my role as a senior nurse leader, and the different factors that have shaped who I am, as a leader. This was particularly the case during the pandemic. The COVID-19 pandemic definitely brought with it a myriad of challenges. Not only did it highlight the vulnerabilities in our healthcare system, it also highlighted the important role of nurses in providing safe and effective care to our patients, in delivering life-saving measures, in keeping our community healthy, and in supporting our learners and new nurses. During the pandemic, I was working as a senior nurse leader in a large academic/quaternary health sciences centre in south-western Ontario, and faced many complex challenges, during a highly stressful and ambiguous time. It was certainly a test of my leadership capabilities.

This paper is written to share my personal reflections about leadership. It is divided into three parts. Part one will focus on the Strengths Within, and I will do this by sharing my personal and professional journey, reflections, and lessons learned as a leader over the past 20 years. Part two will focus on Strengths in Others. In this section, I will describe strengths-based leadership, and compare this with the Canadian College for Health Leaders’ LEADS in a caring environment capabilities framework. The third and final part will focus on Collective Strengths, and I will discuss how leaders can draw on their values and strengths, and the collective strengths of a team, in a time of crisis.

PART 1: FINDING MY STRENGTH WITHIN

I was born and raised in the Philippines. The notion of hard work and having advanced education, was instilled in my cousins, brother, and in me growing up. My grandmother would give us monetary incentives for every “A” we received in our report cards. In the late 1980s, after the Filipino People’s Revolution that ended Martial Law in the Philippines (Govph, n.d. )and after years of political and financial instability, my parents decided to immigrate to Canada to create a safe space for their two young children to grow and thrive. My father, a small business owner, sold his business; and my mother, a regional nursing lead for public health, quit her job. They knew that immigrating to Canada would mean they would have to start over. I was 12 years old and had just finished the sixth grade when we immigrated to Canada.

As immigrants, my parents worked very hard to meet our day-to-day needs, often working over-time and sometimes even holding two jobs. My father got a job as a general helper at a local towel factory. My mother tried to gain employment as a public health nurse, but despite her 20-year public health “experience or qualifications, [it was] deemed not equivalent to the Canadian standard” (Lee et al., 2021, p. 52). She was, however, hired as a nurse in a retirement home and worked as a registered nurse (RN) in the long-term care sector. Nurses are in high demand in these facilities, where a disproportionate number of internationally educated healthcare professionals have been employed (Flecker, 2002). Thus, our early life in Canada as immigrants instilled some values for me: (1) hard work; (2) courage; and (3) be resourceful and innovative. These are values that I still hold as a leader today.

I became a single, teenage mom at the age of 19. This came with its own set challenges, but also empowered me to work harder and pursue higher education. I completed my nursing degree and was drawn to oncology nursing, inspired by my mom who survived uterine cancer in her early 40s. Four years after becoming a nurse, I completed my Master’s degree in nursing, specializing in Health Policy and Education. This prepared me for my first formal leadership role as an Advanced Practice Clinical Educator in Malignant Hematology. In this role, I learned about leadership, project management, leading with curiosity, and the power of collaborating with others to achieve a goal.

This was also the year I received my certification as a specialized oncology nurse and co-led a provincial initiative with leaders from the DeSouza Institute. The Institute is an organization that offers health professionals courses to enhance their knowledge and “expertise to provide the best possible cancer and palliative care” (DeSouza Institute, 2024). This collaboration led to the development of a provincial study group in Ontario to support 107 oncology nurses preparing for the Canadian Nurses Association (CNA) Oncology Certification Exam (Rashleigh et al., 2011). This initiative was seen as an innovation and enabled oncology nurses, from 17 different healthcare organizations in Ontario, connect remotely using technology and learn from various oncology nurse experts across the province. The result was an examination success rate of 94% (Rashleigh et al., 2011). As a novice leader, I knew I did not have the knowledge or skills to lift this initiative alone and sought support from other, more experienced leaders. The program was successful largely because of a group of leaders who shared a common vision to achieve a common goal of increasing the number of certified oncology nurses in Ontario.

My early years provided me with some very valuable lessons and core values as a leader: courage, innovation, having an open-mind, and humility. Courage is about doing the right things and challenging the status quo. Innovation means you can think ‘outside the box’ when challenges arise, and resources are scarce. Having an open mind means being ready to hear and explore new ideas, perspectives, and learning. Humility means knowing when I do not know the answer and being ready to ask for help when it is needed. Having an experienced oncology nurse mentor who connected with me regularly was perhaps the single most valuable contributor to my growth and success as a leader. My mentor was able to provide me with a different perspective, which allowed me to find alternate paths to solving problems. I think this type of problem-solving and finding new pathways would have been very difficult to do on my own.

PART 2: FINDING STRENGTH IN OTHERS : CREATING PARTNERSHIPS AND DEVELOPING PEOPLE

2015 was a big year for me. At this time, I completed my Doctoral Degree in Education and strengthened my knowledge and skills in the development and evaluation of educational programs in oncology. I also joined the Canadian Association of Nurses in Oncology (CANO/ACIO) as a board member, and took on the Director-at- Large, Education portfolio. CANO/ACIO is a national organization with a mission to advance oncology nursing excellence through practice, education, research, and leadership for the benefit of all Canadians, and a vision of being an international nursing leader in cancer control (CANO, 2019).

In alignment with CANO/ACIO’s mission, the CANO/ACIO Education Committee developed a few educational initiatives to support the advancement of specialized oncology nursing excellence. By leveraging the skill sets I had, and being on the CANO Board of Directors, I was able to widen my network and continue to engage with other oncology nurse leaders and experts across Canada to develop the learning pathway for the specialized oncology nurse. We worked on this initiative for about a year and held an in-person meeting at the 2017 CANO Conference in Lac Leamy, Quebec. Meeting in person fostered open dialogue, which allowed us to achieve consensus as a group and defined the key foundational knowledge areas, specialization, and professional development needed for specialized oncology nursing (CANO, 2018).

Having these experiences with the professional specialty organization set me up for success in obtaining a senior-level leadership role in an oncology care facility. In 2015, I also took on my first senior leadership role in oncology. I soon realized that I had under-estimated the amount of learning, leadership growth, and emotional maturity required to lead at this level. I sought mentorship and support from other senior nurse leaders to help me navigate through complex and socio-politically charged situations.

One leadership framework that I learned about is the LEADS in a Caring Environment capabilities framework, which “presents a common understanding of what good leadership looks, feels, and sounds like across all levels of service provision in healthcare” (Canadian College of Health Leaders [CCHL], 2024, para. 1). In the LEADS framework, there are five domains, each one consisting of four capabilities, reflective of the current literature on health leadership and leadership development. These domains are Lead Self, Engage Others, Achieve Results, Develop Coalitions, and Systems Transformation (CCHL, 2024). The table below provides a summary of the capabilities within each domain.

Table 1.

LEADS in a Caring Environment Domains and Capabilities

Lead Self: Self-motivated leaders… Are self-aware Manage themselves Develop themselves Demonstrate character Engage Others: Engaging leaders… Foster development of others Contribute to the creation of healthy organizations Communicate effectively Build teams Achieve Results: Goal-oriented leaders… Set direction Strategically align decisions with vision, values, and evidence Take action to implement decisions Assess and evaluate Develop Coalitions: Collaborative leaders… Purposefully build partnerships and networks to create results Demonstrate a commitment to customers and service Mobilize knowledge Navigate socio-political environments System Transformation: Successful leaders… Demonstrate systems/critical thinking Encourage and support innovation Orient themselves strategically to the future Champion and orchestrate change

Adapted from the Canadian College of Health Leaders Website, 2024, from The LEADS Framework (cchl-ccls.ca)

I anchored my leadership style in the LEADS framework, and found it aligned with my own values as a leader. I have even used this framework when leading complex and large-scale transformational initiatives. I found it was specifically helpful to inform the change management process. While many leadership theories focus on setting a vision, engaging others, achieving results, and systems thinking, the LEADS framework also adds a focus on leading oneself, and understanding emotional intelligence. It encourages leaders to be introspective in their approach, so they can continue to grow and be better leaders.

Engaging others, a domain within the LEADS framework, indicates that leaders who wish to involve others communicate effectively, foster the development of others, and build teams. Armed with the key learnings and skills gained from various sources, such as from my life experiences, work experiences, mentors, and formal educational preparation, I was able to lead more effectively in the midst of ambiguity and was eventually able to start providing mentorship to other emerging oncology nurse leaders. Mentorship is defined as “a relationship between two people where the individual with more experience, knowledge, and connections is able to pass along what they have learned to a more junior individual within a certain field” (Oshinkale, 2019, para. 2). I supported and mentored novice educators, and clinical leaders, by providing them with guidance on educational program development and evaluation, or how to carry out large complex change initiatives in organizations.

Fostering the development of others is another capability within the LEADS framework that I found extremely valuable as a leader. Not only did I learn in the process of developing others, but it also gave me joy in the work. I found the experience so rewarding to watch emerging leaders thrive. When leading a team, it is important to provide opportunities for team members to grow and develop the skills required to be successful in their roles while building them up as leaders. This not only builds a stronger team, as a whole, but also creates a space for learning new things. One particular example that comes to mind occurred when a colleague and I provided mentorship to an oncology clinical educator. The clinical educator learned the Kirkpatrick Model for evaluating training effectiveness, and she was able to apply it in clinical practice successfully. She also learned about how to design evaluation tools, collect and analyze data, and write the results for publication (Page et al., 2021). Now that she has the skills for evaluating training programs, she can shine this light onto other members of the team by sharing her knowledge with others.

PART 3: COLLECTIVE STRENGTHS: LEADING A HIGH PERFORMING TEAM

It was in the early 2020s, when the healthcare system faced one its greatest challenges: the COVID-19 pandemic happened on a global scale. Our healthcare system’s capacity was extremely pressured, with patients requiring hospitalization and many needing critical care. Unconventional bed spaces had to be used, hallway medicine increased, and some organizations even used their auditoriums for admitted patients. At the same time, many healthcare workers, including nurses, made the difficult decision to retire or leave the profession they loved, leading to a global nursing crisis. Oncology healthcare leaders and administrators were not only dealing with the pandemic, but they were also having to deal with capacity, flow, and staffing pressures. Many of the oncology services were paused, while other life-saving measures, such as the administration of systemic and cellular therapies and/or conducting urgent surgical procedures continued. I remember in one of the oncology inpatient units in the centre where I worked, the nurse-to- patient ratio went up to a high of 1:10 during a night shift. Oncology nurse leaders had to be strategic to find innovative ways for supporting nurses in providing safe care, and to find funding for additional resources.

Paterson et al. (2020) listed the strategies to maintain business operations during a crisis to maintain space capacity, hospital flow, and staffing pressures. These include having staff alternate work agreements, planning for consolidation of services and alternate approach for low staffing, having emergency privileges, hiring temporary staff, and ensuring staff crosstraining. As a senior nurse leader, like many others world-wide, I was asked to help lead many of the initiatives aimed at maintaining operations and care delivery. The initiatives included implementation of alternate models of care (e.g., crisis model of care that enabled nurses to care for many patients with the help of extenders), re-deployment of ambulatory care nurses to inpatient and critical care units, and becoming part of a task-force that planned the operational and clinical model within a “field hospital” (i.e., an 80-bed temporary facility, that looked like a military tent).

While these initiatives during the pandemic were high-stakes, complex, and stressful, they offered a critical learning process. It was during this time that I learned more about leadership, about systems thinking, and about who I am, as a leader. Often, during uncertain and ambiguous times, it may be easy for leaders to feel stress, or become overwhelmed, and make decisions anchored in fear (Brown, 2021). Recognizing that I was going down this path, I again anchored myself using the LEADS Framework, and tried to really have a solid understanding of my own skill sets, and the knowledge and skills that I still needed to develop.

Making decisions that impacted others, especially during a crisis, such as developing the team-based/alternate model of care for nursing and a re-deployment framework, was not easy. However, engaging with other leaders and nurses to listen to their concerns and needs was a critical step in this development process. Oncology nurses advocated strongly for their patients, especially for additional resources to ensure that their patients were receiving the highest quality of care. They also wanted to make sure they were able to provide supportive care, and holistic care for their patients with cancer. In one of the oncology inpatient units where I worked, many nurses from the outpatient clinic were re-deployed to this unit as extenders to support the inpatient nursing model. Some physicians also volunteered to help them with select nursing tasks. The oncology local leadership team met with re-deployed staff, provided them with support, and made them feel part of their oncology team. The oncology leadership team developed scripts, checklists, role and responsibilities resources that were later adapted and implemented organizationally by other programs. When the COVID-19 vaccine became available, oncology nurses advocated for their most-vulnerable and immuno-compromised patients to be prioritized in receiving the vaccine.

During the pandemic, other strategic initiatives were being explored at Hamilton Health Sciences (HHS) to strengthen our nursing recruitment and retention efforts. The Internationally Educated Nurse (IEN) Integration Program at HHS quickly learned that there was a large number of IENs who were having challenges meeting some of the requirements to obtain their registration with the College of Nurses of Ontario (CNO). The challenges were observed particularly in meeting the recent evidence of practice and in demonstrating English Language Proficiency, because of some travel restrictions. The CNO requires applicants to demonstrate that they “have experience practicing as a nurse within the past three years” (CNO, 2024, para. 2). For some IENs whose evidence of safe practice is outside of this timeframe, they have the option to either return to their country of origin to which they are registered to practice, or go through an evaluation process with the CNO Registration Committee and successfully complete any additional training or assessments. The second option can be a lengthy process, therefore many IENs choose to return to their country of origin where they are registered to practice. However, with the travel restrictions, this option was delaying their ability to obtain their CNO registration and join the nursing workforce.

The IEN Integration Program at HHS collaborated with the CNO to develop a pilot program and help solve this problem. The pilot program enabled IENs to demonstrate their evidence of safe practice and English language proficiency at HHS with a preceptor, thereby providing the IENs with the opportunity to meet the requirements for their CNO registration without having to go back to their home country. The HHS nursing leadership team also sought the support from the Ontario Ministry of Health Workforce Planning Branch. With funding from the Ministry and support from CNO, the pilot at HHS was launched with much success. The inpatient hematology/oncology unit leaders at HHS were one of the first groups to volunteer to participate in this pilot initiative. By developing coalitions with other agencies, HHS’ pilot program became a transformational initiative that was implemented provincially in Ontario. This is an example of challenging the status quo by thinking about different ways to tackle a problem and developing partnerships with other organizations to solve a problem.

The LEADS in a Caring Environment capabilities framework was a tool that I followed closely when leading largescale and complex initiatives, and I found it to be especially useful when leading during a crisis. It allowed me to think about change, the people that I needed to partner with, and the many internal and external factors that we needed to address if we were to manage the change successfully. However, there is another leadership theory that I recently learned about and is now part of my leadership toolkit, called strengths-based leadership. From my experience, this is very similar to the LEADS Framework.

STRENGTHS-BASED LEADERSHIP

Gallup Inc., an American analytics and advisory company, reviewed decades of data from research studies, polls, and interviews with senior leaders, to understand better what influential leaders do best. They found that influential leaders are always investing in their own strengths, surrounding themselves with the right people and maximizing their team, and working to understand their team members’ needs (Rath, 2008). In other words, the most influential leaders engage in strengths-based leadership.

Strengths-based leadership is a method of maximizing the efficiency, productivity, and success of an organization by focusing on and continuously developing the strengths of organizational resources, such as computer systems, tools, and people. At the core of the strengths-based leadership is the underlying belief that people have several times more potential for growth building on their strengths rather than fixing their weaknesses (Burkus, 2023 para. 1).

Dr. Donald O. Clifton, the father of strengths psychology who conducted more than three decades of research, described the importance of leaders knowing their strengths, and having the ability to call on the right strength when needed (Rath, 2008). Equally important is for leaders to help others uncover and build their strengths, and to create a team that has complementary strengths, thereby creating “more rapid individual and organizational growth” (Rath, 2008, p. 17). Strengths-based leadership consists of 34 themes, clustered into four domains: executing, influencing, relationship building, and strategic thinking. Table 2 provides a summary of the themes and domains.

Table 2.

The Four Domains of Leadership Strength

Executing	Influencing	Relationship Building	Strategic Thinking
Achiever	Activator	Adaptability	Analytical
Arranger	Command	Developer	Context
Belief	Communication	Connectedness	Futuristic
Consistency	Competition	Empathy	Ideation
Deliberative	Maximizer	Harmony	Input
Discipline	Self-assurance	Includer	Intellection
Focus	Significance	Individualization	Learner
Responsibility	Woo	Positivity	Strategic
		Relator

Adapted from Gallup, Inc. (2009). The strengths of leadership. Business Journal. Retrieved from The Strengths of Leadership (gallup.com)

Leaders can have strengths within each of the four domains, but they can also have dominant strengths clustered in one domain. For example, leaders who are dominant in the executing domain are able to achieve outcomes and make things happen, while leaders who lead through influencing are strong communicators who can reach a broader audience (Rath, 2008). Leaders who are strategic thinkers are always analyzing information and helping their team members make better decisions for the future, while leaders who are relationship builders are able to create strong teams that involve the larger group. When leaders understand their own strengths, they can continue to focus on their strengths and use them when needed. They can also identify the different strengths that exist within their teams and can therefore build a high performing team.

The strengths-based leadership theory has allowed me to become a better leader, as I have learned not only to embrace my own strengths, but also to understand my team members’ strengths better and to leverage them. I have completed the Gallup’s CliftonStrengths® Assessment through the Leadership Program at Trillium Health Partners (THP), and have learned that my strengths are achiever, focus, significance, relator, and futuristic. While I have strengths in each of the domains, my dominant strength is Achiever. By understanding my strengths, I can also have insights into where my blind spots can be, and the strengths that I need to leverage in my team members in order to unleash a high-performing team.

The LEADS in a caring environment framework and the strengths-based leadership theory have many similarities. The first capability in the LEADS framework is Lead self, which is the very notion of strengths-based leadership; leaders ought to know themselves and their strengths to be better leaders. In the LEADS framework, Engage others is similar to the Influencing domain, which involves fostering the development of others, maximizing the strengths of them members, and building teams. Achieve results and Achiever are the same and Develop Coalitions is similar to Relationship Building. Finally, System Transformation has the same attributes as Strategic Thinking as both involve thinking about the future, and strategically orchestrating transformational change.

POST PANDEMIC

The oncology nursing workforce and the healthcare environment we have now is much different than what it was pre-pandemic. Our healthcare system’s capacity and resources have been tested, including our ability to respond to a crisis in a timely and effective manner. Oncology nurses and leaders have collectively worked through multiple challenging scenarios over the past few years, and we have needed to find new and innovative ways to address staffing challenges and deliver care differently. Today, as we continue with our post-pandemic recovery efforts, nurses and nurse leaders must continue to work together to support each other. As a collective whole in the nursing workforce, we need to support our learners and novice nurses who are new to the profession and are learning the art and science of nursing. This is also a call to action for all leaders in oncology nursing: it is important for all of us to start to pay attention to how we support each other. We need to continue to lift each other up, support our new and emerging leaders, and shine a bright light to those around us. Our strength, as nurses and leaders during a time of crisis, comes from within us, from each of us, and together, as a collective whole.

LESSONS LEARNED AND CONCLUSION

As I reflect on my career and this incredible journey, from my time growing up in the Philippines, to navigating our new life in Canada, being a single- teenage mom, finding my passion in oncology, and now, as a senior leader, I now understand how all of these life experiences have shaped my values and approach as a leader. Throughout the years, I have received mentorship from multiple leaders who have provided me with guidance, advice, coaching, and support; each one offered a different and unique perspective on how to tackle challenges thoughtfully and strategically, how to think clearly, and how to be an effective and impactful people-leader.

When leading in a time of crisis, it is important for leaders to find their strengths within themselves, as well as find strength in others. Our role, as leaders, is to bring out the best in others. Then, we must use the strength of the collective whole to inspire and lead a high-performing team, through empowerment, partnership, and collaboration. Establishing partnerships and coalition, especially with individuals who bring a diverse skill set, or those from other departments, can lead to innovative thinking and creative problem-solving.