Development of exemplary leadership in nurse managers: An Evidence

Development of exemplary leadership in nurse managers: An Evidence Based Practice Project Paula F. Coe MSN, RN, NEA-BC York College of Pennsylvania 1

Objectives Discuss the factors that contribute to the need for a nursing leadership evidence based project Explore the impact of nurse manager leadership practices on organizational outcomes Describe search strategies and evaluation of the literature Illustrate the evidence regarding TL, exemplary leadership practice, RN satisfaction and retention Summarize the evidence and recommendations for translation of practice 2

“It is impossible in a book to teach a person in charge of the sick how to manage, as it is to teach her how to nurse.” Florence Nightingale, 1860 3

John Hopkins Model –Project Management Practice Question (Steps 15) Recruit team Develop and refine the question* Define the scope of the EBP question and identify stakeholders* Determine responsibility for project leadership* Schedule team meetings Evidence (Steps 6-10) Conduct internal and external search for evidence* Appraise the level and quality of each piece of evidence* Summarize the evidence* Synthesize overall strength and quality of evidence* Develop recommendations based upon strength of evidence* (Dearholt & Dang, 2012) 4

Why focus on nursing leadership? The transformational leader must lead people to where they need to be in order to meet the demands of the future (ANCC, 2013) Nurse Managers (NM) have a direct impact on both clinical and organizational outcomes (Zori, Nosek,& Musil, 2010) Leadership ability, lack of support, guidance and engagement issues with the NM impact RN satisfaction. (Fenimore & Wolf, 2011) 5

Responding to the call for action Institute of Medicine-Future of Nursing Report (IOM, 2010) Imperative to prepare nurses for leadership Future of nursing depends upon educating and supporting all levels of nurse leaders Recommendation for nurse residency program Could include a nurse leader residency? 6

The reality of the nursing shortage Lack of good management and leadership contributes to nurses leaving their positions. National Sample Survey of Registered Nurses (NSSRN, 2008). Bedside RN Turnover in the US 13.50 13.00 13 12.50 Less than 48.2 % of hospitals have developed strategies to ensure a formal mechanism to prevent or reduce turnover and retain RNs. (NSI, 2013 ) 12.00 11.50 11.2 11.00 10.50 10.00 RN turnover 2013 2012 (NSI, 2013 ) 7

Transformational Leadership Transformational leadership (Casida & Parker, 2011) Vision Risk taking Aptitude for motivating others Role model Mentor Investing in capable and effective leaders are paramount to contributing to the mission and bottom line of a hospital (Casida & Parker, 2011) 8

Nurse Manager Development Nurse’s don’t often assume the role of NM by choice Few receive structured development beyond initial orientation (Sherman, Bishop, Eggenberger, & Karden, 2007) Continuing education is usually the route NM take to increase knowledge and skills (Sherman, Bishop, Eggenberger, & Karden, 2007) The NM have the responsibility for leading unit activities which empower and engage clinicians accountable for care and patient outcomes (Carthart, Greenspan, & Quin, 2010) 9

Nurse Manager development continued Many nurses become leaders without formal education or on the job education needed to succeed in their role (Kerfoot, 2008) Trial and error development often equates to failure for nurse leaders/managers (Swearingen, 2003) Many nursing leadership programs lack connection to leadership development theories and conceptual frameworks (Galuska, 2013) 10

Influence of the Nurse Manager Role of NM is critical and pivotal to engaging employees and sustaining healthy work environments (Bowles & Candela, 2005) NM leadership behaviors influence nurses to impact outcomes and performance (Germain & Cummings, 2010) Skills and competencies of the NM can influence: Support Feedback Engagement Fostering quality improvement for the NM is imperative in uncertain and volatile healthcare environment (Marshall, 2011) 11

YH- RN satisfaction with NM Internal Goal: Outperform the NDNQI Teaching benchmark the majority of the time Job Satisfaction Scale- RN Survey used 2007-2012 RN satisfaction with NM has not been above benchmark for the past three years (2011, 2012, 2013) despite focused attention with action plans 1 2

2014 NDNQI RN Survey (PES) Nurse Manager Ability, Leadership, and Support of Nurses: York Hospital 3.05 3.02 3.03 3.02 2.99 3.00 2.99 2.95 2.95 3.02 2.98 2.98 2.96 2.94 2.92 2.90 2.85 2.81 2.80 2.75 No Data 2.70 No Data Avg. All Units YH Magnet PG Mean All Hospital PG Mean Teaching Status PG Mean Bed Size Mean 2011 2012 2013 13

2013 YH RN Satisfaction with NM 14

Reason to invest in NM transformational leadership development Impacts Organizational costs Quality of patient care Staff nurse satisfaction Retention and turnover Executive leaders are responsible for developing capacity and providing active involvement in the NM Cummings et al, 2008; Cowden, Cummings,& Profetto-McGrath, 2011; Jones & Gates, 2007; Fenimore & Wolf, 2011) 15

Exemplary Leadership Model and Learning Practice Inventory (LPI) Kouzes and Posner originally published the Five Practices of Exemplary Leadership in 1985. The LPI approaches leadership as a measurable, learnable and teachable set of behaviors The LPI measures the frequency of specific leadership behaviors(LPISelf; LPI-Others) Five core practices emerged from “personal best” leadership stories Model the Way Inspire a Shared Vision Challenge the Process Enable Others to Act Encourage the Heart 16

“To be "in charge" is certainly not only to carry out the proper measures yourself but to see that every one else does so too; to see that no one either willfully or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed.” Florence Nightingale 17

PICO Question Does a structured leadership development program for acute care nurse managers (NM) using the five practices of exemplary leadership model improve transformational leadership (TL) behaviors, RN satisfaction and RN retention compared to no participation in a structured leadership development program? 18

Narrowing the scope P Population Acute Care Nurse Managers I Interventio n Five practices of exemplary leadership model C Compariso n No program O Outcome TL Leadership RN Satisfaction Retention 19

Search Strategy Databases used: CINAHL MEDLINE PsychInfo OVID PubMed Google Scholar Cochrane Collaborative Dates of evidence review included 2000-present 20

Keywords Nurse Manager Nurse leader Nursing leadership Transformational leadership* Nurs* leader Leadership Practices Outcomes Satisfaction Nurs* satisfaction Work environment Retention Management 2 1

Inclusion and Exclusion Criteria Inclusion Acute care NM Hospitals in the United States Leadership development Educational programs Organizational outcomes Work environments Exclusion Nurse Managers from long term care Other NL positions: Directors, Vice Presidents Chief Nursing Officers Leadership competencies Educational programs not focused on NM 2 2

Findings Level of Number evidenc of e researc h articles Level I Level II Level III Level IV Level V 0 2 23 0 7 Quality of the evidence A B C 2 11 4 8 4 1 2 23

Types of research/literature reviewed Quantitative (18) Systematic Reviews (6) Systematic Literature Review (1) Descriptive Cross Sectional (4) Quasi Experimental (1) Pre-Post Survey (3) Exploratory Correlational (1) Qualitative (14) Metasynthesis (1) Descriptive (2) Grounded Theory (2) Interpretive Phenomenology (2) Non Research (7) Action Research (1) Non experimental predictive design (1) 2 4

Exemplary Leadership Model and LPI The LPI was developed through qualitative and quantitative research methods and studies. 3million surveys have been analyzed 1.1million observers 200,000 leaders Reliability routinely tested through analysis of internal reliability all 5 practices have demonstrated strong internal reliability coefficients Results have high face and predictive validity Evidence to support use of this tool and educational program 9 studies reviewed illustrated the use of the LPI and/or the exemplary leadership model with positive outcomes 4 of the systematic reviews discussed use with positive results. LPI-Self and Observer were used by researchers to measure leadership behavior 2 5

Transformational Leadership Twenty eight of the thirty two articles reviewed involved discussion and positive findings of TL related to: Positive organizational outcomes (Wong, Cummings & Ducharme, 2013) Impacted a shared vision and challenge the process (LPI) Improved with leadership development programs (Cummings et. al, 2008; Curtis, Sheerin & deVries, 2011; Heuston & Wolf, 2011; Kleinman, 2004) Achieving effectiveness and leadership outcomes in NM Relationship between TL nursing leadership and patient outcomes (Wong & Cummings, 2007) 26

Registered Nurse Satisfaction RN’s are influenced by the leadership of their NM Empowered NM empower their staff who in turn are more satisfied (MacPhee, Skelton-Green, Bouthillette,& Suryaprakash, 2011) Behaviors utilized by NM can make a difference in employee outcomes Effective TL in NM is essential to creation of work and practice environment (RN Satisfaction) (Pearson et al, 2007) Investment in NM TL style of informing and encouraging staff will enable outcomes of positive work environment and patient care (Germain & Cummings, 2010) 27

Registered Nurse Retention An effective frontline NM is key to retention of staff (Heuston & Wolf, 2011) NM has a direct impact on retention and recruitment (Swearingen, 2009) NM TL practices influence staff nurse retention and builds on the intent of the RN to stay (Cowden, Cummings, & ProfettoMcGrath, 2011) Empowered nurses are committed to their organizations (MacPhee, Skelton-Green, Bouthillette, & Suryaprakash, 2011) 28

Summary of findings High quality Level II A evidence- 2 systematic reviews: High-Good quality Level III A evidence High-Good quality Level V evidence Positive outcomes related to TL development programs and outcomes related to patients and staff Moderate outcomes describing the relationship of using the Exemplary Leadership model The LPI –Self and LPI-Observer tool has demonstrated high reliability and validity over years of testing 29

Recommendations TL behaviors and practices can influence organizational achievement of outcomes for bedside RN’s and for patients Effective NL by nurse managers and development of TL is essential in the current complex healthcare environment Nurse managers who practice TL ensure a quality workplace and are likely to retain staff (Cowden, Cummings, & Profetto-McGrath, 2011) Develop a structured TL development program for acute care NM at York Hospital to improve TL behaviors, RN satisfaction and RN retention. 30

“Unless we are making progress in our nursing every year, every month, every week, take my word for it we are going back” Florence Nightingale 31

Questions 32

References American Nurses Credentialing Center (2013) 2014 Magnet Application Manual. Retrieved from http://www.nursecredentialing.org/MagnetApplicationHighlightManual Bowles, C., & Candela, L. (2005) First job experiences of recent RN graduates. Journal of Nursing Administration. 35(3) 130-137. Casida, J., & Parker, J. (2011). Staff nurse perceptions of nurse manager leadership styles and outcomes. Journal of Nursing Management, 19, 478-486. . doi: 10.1111/j.1265-2834.2011.01252.x Cathcart, E. B., & Greenspan, M. (2012). A new window into nurse manager development. Journal of Nursing Administration, 42(12), 557-561. doi: 10.1097/NNA.0b013e18274b52d Cathcart, E. B., Greenspan, M., & Quin, M. (2010). The making of a nurse manager: the role of experiential learning in leadership development. Journal of Nursing Management, 18, 440-447. doi:10.1111/j.1365-2834.2010.01082.x. Curtis, E. A., Sheerin, F. K., & DeVries, J. (2011). Developing leadership in nursing: the impact of education and training. British Journal of Nursing, 20(6), 344-352. Cowden, T., Cummings, G., & Profetto-McGrath, J. (2011). Leadership practices and staff nurses' intent to stay: A systematic review. Journal of 33

References Dearholt, S.L., & Dang, D. (2nd Ed). (2012). Johns Hopkins Nursing Evidence Based Practice: Model and Guidelines. Indianapolis, IN: Sigma Theta Tau International. Fenimore, L.,& Wolf, G. (2011) Nurse manager leadership development: leveraging the evidence and system leadership. Journal of Nursing Administration. 41(5), 204-210. Galuska, L.A. (2014). Education as a springboard for transformational leadership development: listening to the voices of nurses. The Journal of Continuing Education in Nursing, 45(2), 67-76. doi:10.3928/00220124-20140124 Germain, P. B., & Cummings, G. C. (2010). The influence of nursing leadership on nurse performance: a systematic literature review. Journal of Nursing Management, 18, 425-439. doi:10.1111/j.1365-2834.2010.01100.x Heuston, M. W., & Wolf, G. A. (2011). Leadership development: Transformational leadership skills of successful nurse managers. Journal of Nursing Administration, 41(6), 248-251. doi:10.1097/NNA.0b013e31821c4620 34

References Nursing Solution, Inc. (2013). 2013 National Healthcare and Registered Nurse Retention Report. Retrieved January 17, 2014 from http://www.nursingsolutions.com.administrators/admin-research/StaffingandWorkforceStudies.apsx MacPhee, M., Skelton-Green, J., Bouthillette, F., & Suryaprakash, N. (2011). An empowerment framework for nursing leadership development: supporting evidence. Journal of Advanced Nursing, 68(1), 159-169. doi:10.1111/j.1365-2648.2011.05746.x Marshall, E.S. (2011) Transformational leadership in nursing: From expert clinician to influential leader. New York: Springer Publishing. Nursing Solution, Inc. (2013). 2013 National Healthcare and Registered Nurse Retention Report. Retrieved January 17, 2014 from http://www.nursingsolutions.com.administrators/admin-research/StaffingandWorkforceStudies.apsx Pearson, A., Laschinger, H., Porritt, K., Jordan, Z., Tucker, D., & Long, L. (2007). Comprehensive systematic review of evidence on developing and sustaining leadership that fosters a healthy work environment in healthcare. International Journal of Evidence Based Healthcare, 5, 208-253. Sherman, R. O., Bishop, M., Eggenberger, T., & Karden, R. (2007). Development of a leadership competency model. Journal of 3 5

References Wong, C. A., & Cummings, G. G. (2007). The relationship between nursing leadership and patient outcomes: A systematic review. Journal of Nursing Management, 15, 508-521. Wong, C. A., Cummings, G. G., & Ducharme, L. (2013). The relationship between nursing leadership and patient outcomes: a systematic review update. Journal of Nursing Management, 21, 709-724. doi:10.111/jonm.12116 Zori, S., Nosek, L.J., & Musil, C.M. (2010) Critical Thinking of Nurse Manager Related to Staff RN’s Perceptions of Practice Environment. Journal of Nursing Scholarship. 42(3), 305-313. 3 6