The Journal of Continuing Education in Nursing

Leadership and Development 

A Systems Approach to Cultivate a Flourishing Nurse Workforce

Jim D'Alfonso, DNP, RN, PhD(h), NEA-BC, FNAP; Peggi B. Winter, DNP, MA, RN, CENP


Large integrated health care systems face myriad challenges in bridging national nursing strategy with functional workstream initiatives. The example of a regional Workforce Workstream is outlined to demonstrate how a national nursing agenda may be successfully operationalized to unite and advance an organization's mission, vision, and values. [J Contin Educ Nurs. 2019;50(6):248–251.]


Large integrated health care systems face myriad challenges in bridging national nursing strategy with functional workstream initiatives. The example of a regional Workforce Workstream is outlined to demonstrate how a national nursing agenda may be successfully operationalized to unite and advance an organization's mission, vision, and values. [J Contin Educ Nurs. 2019;50(6):248–251.]

Nursing is at the heart of Kaiser Permanente's (KP) renowned integrated health care system. KP consists of 12.2 million members, 216,000 employees, 684 medical clinics, 38 hospitals, and more than 60,000 nurses. A systems approach to strategy is necessary to ensure all eight regions deliver on the organization's mission and vision, as nursing continually thrives and evolves to meet the diverse needs of the organization, its members, and the communities it serves (Kaiser Permanente, 2019).

Nurses comprise the single largest group of employees in the KP work-force, and the provision of nursing care touches all settings, including clinics, acute care hospitals, physician offices, retail clinics, large ambulatory centers and patients' homes. KP nurses work across the continuum of care—leading prevention and wellness programs for children and healthy adults and care management for seniors with chronic conditions. They are actively engaged at all levels of the organization—from administration, human resources and marketing, to finance and legal, as well as from government relations to research and innovation (Winter, 2016). Different functional and operational roles help to shape and execute decisions regarding all facets of strategy and management of the organization, providing the rationale for a national nursing professional strategy agenda (NNPSA) to ensure a united voice and framework for how KP nursing organizes, operates, and communicates. The national nursing agenda is led by KP's Senior Vice President of Nursing in collaboration with leaders throughout the organization, in all regions, nursing and non-nursing. The NNPSA was initially rallied around a revision and refresh of the KP nursing vision statement, which reinforced the central role of nursing in delivering on the organization's mission and vision well into the future: “As leaders, clinicians, researchers, innovators, and scientists, Kaiser Permanente nurses are advancing the delivery of excellent, compassionate care for our members across the continuum, and boldly transforming care to improve the health of our communities and nation” (Kaiser Permanente Nursing, 2019, para. 1).

The KP Nursing Professional Model is depicted in Figure 1.

Extraordinary nursing care, every patient, every time.

Figure 1.

Extraordinary nursing care, every patient, every time.

National Nursing Professional Strategy Agenda

Never has it been more important to align and partner with shared areas within the nursing mission of the organization. Operationalizing the mission requires close collaboration with regional chief nurse executives and effective partnerships with other disciplines; in response, a new work group structure was formed to align with the NNPSA goals and objectives of quality and safety, work-force development, and evidentiary nursing practice. These work groups helped to identify the present state of nursing, envision the future state, and clarify specific workstreams for organizing and implementing the NNPSA across all regions. Team charters were developed with clear quantitative and qualitative outcome measures to ensure clarity, visibility, tracking, and cross-regional communication of progress toward defined national goals.

The National Workforce Workstream

The mantra of the national Work-force Workstream was “optimize for today and prepare for tomorrow,” which evolved out of an assessment of the internal workforce trends and included parallel efforts to help forecast future nursing workforce needs, such as new technology, population health trends, and other reliable external resources. Workforce predictions are complex and begin by predicting how known and unknown factors may influence supply and demand, clinical practice, and organizational resilience in the face of constant change. Change is a constant in health care today, and cultivating transformational leaders is essential to provide quality, safety, and exceptional service while promoting affordability through ongoing operational excellence. The Workforce Workstream seeks proactive solutions to challenges in recruitment and retention, succession planning, leader development, onboarding, career mapping, and generally preparing the workforce of the future. The unknowns to a stable and thriving workforce are many and include potential economic downturns or upturns, changes in health care laws, and new methods and modes of health care delivery (“The U.S. Nursing Workforce in 2018 and Beyond,” 2017).

Regional Workforce Workstream in Action

An example of the national Work-force Workstream in action is the KP Nurse Scholars Academy in the Northern California region (NCAL). In close collaboration with National Patient Care Services beginning in 2013, senior leadership in NCAL engaged nurse leaders in a co-creative process to develop a 5-year workforce strategy that would include a pilot for a new nurse scholars academy.

Leading up to the planned implementation of health care reform in California, visioning forums were conducted with front-line nurses across the continuum of care. These interactive forums reinforced the overwhelming desire of nurses at all levels of the organization to have a voice and to play an active role in finding solutions to the challenges accompanying health care reform in order to ensure KP could continue to deliver on its mission (D'Alfonso, Zuniga, Weberg, & Orders, 2016). Nurses were inspired and fully engaged, which helped inform expanded thinking around a more inclusive and comprehensive workforce strategy often referred to by the upbeat and aptly titled slogan “Hearts and Minds.” The 2010 Institutes of Medicine report The Future of Nursing: Leading Change, Advancing Health, as well as other external and internal workforce data, contributed to strategy development. Advancing professional nursing, streamlining the integration of best practices, and nurturing future nurse leaders at all levels of the organization were core themes that emerged out of direct dialogue with nurses.

Seven Strategic Workforce Priorities Emerge

The creation and launch of the KP Nurse Scholars Academy in 2015 was the beginning of a bold 5-year work-force strategy that would integrate the national nursing agenda and support a new approach to assess the impact of the academy's programs on key workforce indicators, while offering an opportunity to spread learning and successful workforce workstream strategies to other regions and across the enterprise. Strategic priorities emerged through the co-creative process with national patient care services, including specific programs focused on:

  • Academic progression.
  • Leadership development.
  • Professional practice.
  • Professional development and education.
  • Evidence-informed practice and research.
  • Community health and the work-force of the future.
  • Nursing legacy.

These seven strategic workforce priorities integrate existing work-force development programs and are reorganized and expanded under the newly formed nurse scholar's academy as distinct workstreams. Detailed forecasting with associated budgets and specific outcome measures were outlined for each workstream. Budgets provided justification and costs related to the addition of essential resources, expansion of internal systems and technology, marketing and funding for programs, tuition, and operational expenses for each year of the 5-year pilot program.

The evolution of the academy required leadership vision and significant funding commitments from the highest levels of the organization, which ultimately allowed strategy to move from paper and vapor to practice and reality. The emergence of the nurse scholar's academy accompanied a sense of organizational readiness and alignment, as well as a willingness to take informed risks in a colossal effort to accelerate a quantum cultural transformation from the inside out and one nurse at a time. The organization was not averse to risk or unaccustomed to investing in bold new initiatives, and nursing has a well-established legacy of disruptive innovation (D'Alfonso, Jones, & Moss, 2018).

Impact and Outcomes

In the first 3 years of the Nurse Scholars Academy, the impact and outcomes have been profound and best measured in the personal stories of those it has touched. More than 1,000 nurses in NCAL have participated in academic progression and leadership development programs through the KP Nurse Scholars Academy. A creative and dynamic RN-to-baccalaureate nursing degree program developed in partnership with Samuel Merritt University has resulted in narrowing the gap from 43% BSN-prepared nurses in 2014 to 72% today, well on the way to the 80% target set forth in the initial strategy. Master of Science in Nursing and Master of Science in Nursing–Clinical Nurse Leader programs for nurse managers are at 116 nurse participants, and doctoral programs (Doctor of Nursing Practice and PhD) are at 56 nurse leaders; both programs are growing. Nurse executives in NCAL are able to pursue either an Executive Leadership Doctor of Nursing Practice or a doctoral program of their choice. A critical workforce outcome metric is a retention rate of 96% and rich diversity of participants for all degree programs scholars. Academic partnerships with the University of San Francisco School of Nursing and Health Professions were recognized by the American Association of Colleges of Nursing in 2018 (American Association of Colleges of Nursing, 2019).

In addition to ongoing leadership development and new leader onboarding efforts across the region, NCAL has introduced accelerated transformational leadership opportunities for developing high-performing leaders as part of continuous succession planning. An innovative fellowship program for nurse executives and nurse researchers has helped bridge retirements and turnover, as well as supported promotions into hospital operations and regional nurse executive roles. Nurse fellowship programs have sustained a 100% promotion and retention rate to date.

Professional practice programs support certification in clinical specialty areas, whereas caring science programs offer nurses the opportunity to become Caritas Coaches and HeartMath® trainers that support self-care practices and healing environments across the region. Clinical nurses have completed advancing care courses and continuing education programs at the point of care. Nursing publications, presentations, and posters have grown consistently each year and are adding to the collective nursing voice and body of professional knowledge.

Community health programs and partnerships support youth career day activities, work study nursing student immersion programs, as well as trained health providers in the Mental Health First Aid program. Scholarships and support are made available for non-employee nursing students and nurses from local safety-net hospitals with defined financial need. Funding is supporting four schools of nursing in California to engage in undergraduate nursing curriculum redesign.

Legacy programs featuring Kaiser Foundation School of Nursing alumni are sharing their wisdom, inspiring a new generation of nurses, and strengthening the brand, identity, and associated pride in being a Kaiser nurse. In 2017, a non-broadcast historical documentary on the Kaiser Foundation School of Nursing alumni received a National Telly Award.

Synergy and Spread

The ultimate test of a successful systems strategy is its ability to cultivate a flourishing, stable, and high-performing workforce. Learning from small tests of change and pilot programs can enhance opportunities to spread successes, ameliorate risks, and streamline evidentiary practices with demonstrated value and proven results to the organization. Close collaboration between national and regional nursing leadership teams helps to ensure alignment and strengthen support for new workforce development strategy and goals. Challenges are inevitable, which emphasizes the importance of a unified leadership vision at all levels of the organization, strong executive support, secure funding, and dedication to transform workforce cultures, to inspire and lift up care teams, and to deliver on the mission.


  • American Association of Colleges of Nursing. (2019). Exemplary academic-practice partnership award winners. Retrieved from
  • D'Alfonso, J., Jones, D. & Moss, T. (2018). Kaiser's school of nursing: A 70-year legacy of disruptive innovation. Nursing Administration Quarterly, 42, 35–42. doi:10.1097/NAQ.0000000000000262 [CrossRef]
  • D'Alfonso, J., Zuniga, A., Weberg, D. & Orders, A. (2016). Leading the future we envision: Nurturing a culture of innovation across the continuum of care. Nursing Administration Quarterly, 40, 68–75. doi:10.1097/NAQ.0000000000000141 [CrossRef]
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  • The U.S. nursing workforce in 2018 and beyond [Supplemental material]. (2018). Journal of Nursing Regulations, 8(Suppl.), S3–S6.
  • Winter, P. (2016). Using a high-performance planning model to increase levels of functional effectiveness within professional development. Journal for Nurses in Professional Development, 32, 33–40. doi:10.1097/NND.0000000000000204 [CrossRef]

Dr. D'Alfonso is Executive Director for Professional Practice and Leadership Development, and Research and Executive Director for Kaiser Permanente's Nurse Scholars Academy, Kaiser Foundation Hospitals/Health Plan; and Dr. Winter is Senior Director of Professional Development and Talent Management, Kaiser Permanente National Patient Care Services, Oakland, California.

The authors are paid employees of Kaiser Permanente. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jim D'Alfonso, DNP, RN, PhD(h), NEA-BC, FNAP, Executive Director for Professional Practice and Leadership Development, and Research and Executive Director for Kaiser Permanente's Nurse Scholars Academy, Kaiser Foundation Hospitals/Health Plan, Northern California Region, 1950 Franklin Street, Oakland, CA 94612; e-mail:


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