Hospital restructuring and nursing leadership: a journey from research question to research program

The 1990s brought new fiscal realities to healthcare, leading to nursing job loss estimates in tens of thousands following widespread hospital restructuring to manage costs and improve efficiency. This research aimed at examining (a) how multiple episodes of hospital restructuring leading to layoff of nurses affected nurses who remained employed and (b) whether and how nursing leadership mitigated or intensified the negative effects of hospital restructuring on nurses. This dissertation comprised 3 empirical studies leading to 5 publications. The first study was a systematic literature review; the second and third used structural equation modeling to develop and test theoretical models addressing nursing practice environments and effects of hospital restructuring on nurses. The combined findings in this dissertation illustrate that hospital restructuring had significant negative physical/emotional health effects on nurses who remained employed. Nurses who worked for resonant (emotionally intelligent) leadership reported positive health and well-being, and opportunities to provide quality patient care. Nurses who worked for dissonant leadership reported greater negative effects of hospital restructuring. These findings led to a beginning theory of relational energy--a mechanism of mitigation whereby resonant nursing leaders invest energy into collaborative relationships with nurses, thereby positively influencing health and well-being, and, ultimately, outcomes for patients.     

Investing relational energy: the hallmark of resonant leadership

Recent research has shown that hospital restructuring that included staff layoff has adversely affected the role, health and well-being of nurses who remained employed. Further research found that nurses working in environments that reflected resonant (emotionally intelligent) leadership reported the least negative effects to their healt and well-being following hospital restructuring. What remained unclear was the mechanism by which this mitigation occurred. The purpose of this paper is to explore additional findings from this leadership research and discuss one explanation unique to the academic literature for the mitigation variable--the investment of relational energy by resonant nursing leadership to build relationships with nurses and manage emotion in the workplace.     

Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review

Context

Numerous policy and research reports call for leadership to build quality work environments, implement new models of care, and bring health and wellbeing to an exhausted and stretched nursing workforce. Rarely do they indicate how leadership should be enacted, or examine whether some forms of leadership may lead to negative outcomes. We aimed to examine the relationships between various styles of leadership and outcomes for the nursing workforce and their work environments.

Methods

The search strategy of this multidisciplinary systematic review included 10 electronic databases. Published, quantitative studies that examined leadership behaviours and outcomes for nurses and organizations were included. Quality assessments, data extractions and analysis were completed on all included studies.

Findings

34,664 titles and abstracts were screened resulting in 53 included studies. Using content analysis, 64 outcomes were grouped into five categories: staffsatisfaction with work, role and pay, staff relationships with work, staff health and wellbeing, work environment factors, and productivity and effectiveness. Distinctive patterns between relational and task focused leadership styles and their outcomes for nurses and their work environments emerged from our analysis. For example, 24 studies reported that leadership styles focused on people and relationships (transformational, resonant, supportive, and consideration) were associated with higher nurse job satisfaction, whereas 10 studies found that leadership styles focused on tasks (dissonant, instrumental and management by exception) were associated with lower nurse job satisfaction. Similar trends were found for each category of outcomes.

Conclusion

Our results document evidence of various forms of leadership and their differential effects on the nursing workforce and work environments. Leadership focused on task completion alone is not sufficient to achieve optimum outcomes for the nursing workforce. Efforts by organizations and individuals to encourage and develop transformational and relational leadership are needed to enhance nurse satisfaction, recruitment, retention, and healthy work environments, particularly in this current and worsening nursing shortage.     

Nursing staff mix models and outcomes

BACKGROUND: Recently, restructuring of the nursing workforce has been undertaken in a number of countries in an effort to provide efficient and cost-effective services to users. This often takes the form of the introduction of unregulated workers to carry out support roles with registered nurses. However, these changes have not been evaluated for efficacy or impact on nurses, patients or the health care system. PURPOSE: The purpose of this study was to determine the relationship between staff mix models comprising regulated staff (Registered Nurses and Registered Practical Nurses) or regulated and unregulated staff (Registered Nurses and unregulated workers), and nursing and quality outcomes. METHODS: This comparative correlational study was conducted in a random sample of 30 adult, acute care patient units within eight hospitals located in Toronto, Canada. Registered Nurses employed on 30 randomly selected hospital units, grouped by the two staff mix models (15 units per group), were surveyed using previously validated instruments to measure role conflict, role ambiguity, job satisfaction, perceived effectiveness of care and perceived quality of care. RESULTS: Results indicated that Registered Nurses in this study experienced high levels of role conflict, regardless of the type of staff mix model within which they worked. Registered Nurses on units employing both Registered Nurses and unregulated workers reported higher levels of job satisfaction. On units employing both Registered Nurses and unregulated workers, Registered Nurses perceived that the quality of care was lower. CONCLUSIONS: Staff mix model was related to Registered Nurses' perceptions of the quality of patient care. It was also evident that other variables within the work environment might have more influence on the outcomes examined than the independent variable of staff mix.     

Voices from the trenches: nurses' experiences of hospital restructuring in Ontario

Nurses, the largest occupational group in health care, have been disproportionately affected by health care restructuring initiatives. A survey of registered nurses in Ontario was conducted in the fall of 1998 to examine factors influencing their work life quality in hospital settings. As a part of this survey, respondents were provided with an opportunity to share their concerns about work conditions in an open ended section of the questionnaire. Almost sixty percent of the nurses chose to respond to the open ended question (n = 230), divided equally between males and females. The purpose of the qualitative component of the study was to obtain a more in depth analysis of the effects of hospital restructuring initiatives on staff nurses' working conditions. All geographic areas of the province were represented in the responses. A content analysis of the data was conducted to determine major themes. Similar themes were found across all geographic areas. The four major categories of concerns that emerged from the qualitative analysis were quality of worklife, quality of patient care, relations with management, and cumulative impact of work conditions on feelings and attitudes. Nurses' perceptions of their quality of work life, concern for the quality of patient care and their emotional and attitudinal responses were very similar to those reported in a recent study of hospital staff nurses in the United States. The decade of the 1990's has been characterized as one of constant change bordering on chaos within the health care system in Canada and the United States. In Canada, government fiscal policies have resulted in less money being directed toward health care forcing the system to reorganize in order to meet new financial realities. Many of the organizing efforts have been directed toward the acute care sector of the health care system. Nurses, as the largest occupational group within the health care system, have been disproportionately affected by these efforts. The purpose of this study was to tap nurses concerns about the effects of these changes on their personal and work experiences.     

The impact of emotional intelligence in health care professionals on caring behaviour towards patients in clinical and long-term care settings: Findings from an integrative review

BackgroundOver recent years there has been criticism within the United Kingdom’s health service regarding a lack of care and compassion, resulting in adverse outcomes for patients. The impact of emotional intelligence in staff on patient health care outcomes has been recently highlighted. Many recruiters now assess emotional intelligence as part of their selection process for health care staff. However, it has been argued that the importance of emotional intelligence in health care has been overestimated.ObjectivesTo explore relationships between emotional intelligence in health care professionals, and caring behaviour. To further explore any additional factors related to emotional intelligence that may impact upon caring behaviour.DesignAn integrative review design was used.Data sourcesPsychinfo, Medline, CINAHL Plus, Social Sciences Citation Index, Science Citation Index, and Scopus were searched for studies from 1995 to April 2017.Review methodsStudies providing quantitative or qualitative exploration of how any healthcare professionals’ emotional intelligence is linked to caring in healthcare settings were selected.ResultsTwenty two studies fulfilled the inclusion criteria. Three main types of health care professional were identified: nurses, nurse leaders, and physicians. Results indicated that the emotional intelligence of nurses was related to both physical and emotional caring, but emotional intelligence may be less relevant for nurse leaders and physicians. Age, experience, burnout, and job satisfaction may also be relevant factors for both caring and emotional intelligence.ConclusionsThis review provides evidence that developing emotional intelligence in nurses may positively impact upon certain caring behaviours, and that there may be differences within groups that warrant further investigation. Understanding more about which aspects of emotional intelligence are most relevant for intervention is important, and directions for further large scale research have been identified.     

Governance education for nurses: Preparing nurses for the future

The complexities of today's health care environment require organizational governing boards to have deeper understanding of health needs, influences, and outcomes with diverse board leadership. Nurses understand the complexities and demands of health care, but few nurses are engaged on boards of directors and many nurses feel unprepared for the governance leadership role. The nurse of the future requires governance knowledge and competencies to influence organizational policies that will improve health care outcomes and advance health promotion. Governance education is a necessary component of preparing the nurse of the future to influence health care transformation. Until nurses can confidently embrace governance leadership as a part of their professional identity, convincing and expecting non-nurse board leaders to appoint nurses to boards will continue to be a challenge. This paper describes a strategy for incorporating governance competencies into nursing curricula across all education levels by leveraging the American Hospital Association Governance Core Competencies (2009) and the Massachusetts Nurse of the Future Core Competencies©-RN (Massachusetts Department of Higher Education Nursing Initiative, 2016).     

Nursing and health care reform: implications for curriculum development

The health care system is undergoing profound changes. Cost containment efforts and restructuring have resulted in cutbacks in registered nurse (RN) positions. These changes are often related to the increased market penetration by managed care companies. To determine how RN graduates perceive these changes and their impact on the delivery of patient care, Healthcare Environment Surveys were mailed to graduates of the classes of 1986 and 1991. Using the Survey's 5-point Likert Scale, we measured the graduates' satisfaction with their salary, quality of supervision they received, opportunities for advancement, recognition for their job, working conditions, the overall job and the changes in their careers over the previous five year period. Our study suggests that the changes in the health care system are having an impact on how health care is being delivered and the way nurses view their jobs. Respondents reported that insurance companies are exerting increased control over patient care and perceive that the quality of patient care is declining. Increased workloads and an increase in the amount of paperwork were reported. Participants perceived that there were fewer jobs available and that job security was decreasing. The percentage of nurses who see job satisfaction as remaining the same or increasing are a majority. However, the relatively high percent of nurses who see job satisfaction as declining should provide a note of warning. The major implications of this study are that the professional nursing curriculum must be modified to include content on communication, organization, legislative/policy skills, and leadership. The nation's health care system is undergoing profound changes. There are numerous forces at work that are effecting the delivery of care and, consequently, the work of health professionals. These forces include significant efforts at cost containment, restructuring and downsizing of hospitals, and the movement of health care delivery out of acute care centers and into the community. Even though cutbacks in registered nurse (RN) positions appear to have leveled off in sections of the country that have gone through restructuring and reengineering of the work place, there still remains a heavy emphasis on lowering costs by decreasing employee benefits and increasing productivity through the substitution of part-time RNs for full-time RNs and the substitution of unlicensed assistive personnel (UAP) for RNs. These changes are often related to the increased market penetration by managed care companies, which are not expected to abate any time soon. It is important to determine what impact these changes are having on the delivery of patient care since there is some evidence to suggest that reduction in nursing staff below certain levels is related to poor patient outcomes (Fridken et al, 1996). It is also important to assess the effect of system changes on the satisfaction level health professionals have in their jobs. This is particularly important since some researchers suggest that job dissatisfaction, over a period of time, can result in burnout and eventually, turnover (Cameron, Horsburgh, & Armstrong-Stassen, 1994; Cotterman, 1991). Finally, understanding the impact of these health care delivery system changes has significant implications for baccalaureate nursing education and the preparation needed by future nurses to help them adjust to the changed environment.     

Comparison of nurse, system and quality patient care outcomes in 8-hour and 12-hour shifts

BACKGROUND: Many nurses desire 12-hour shifts. However, there are concerns about implementation. OBJECTIVE: We sought to compare the effects of 8- and 12-hour shifts on nurse, system, and quality patient care outcomes. METHODS: We used a cross-sectional design with data collected from multiple sources in 2003-2004, including a nurse survey and administrative and patient records. We studied hospital nurses and patients in general adult wards, with outcomes including burnout, job satisfaction, scheduling satisfaction, preferences, intention to stay, and employee safety. System outcomes included recruitment and turnover, staffing, absenteeism, and related costs. A variety of quality patient care outcomes were measured from the 3 different types of data. RESULTS: Thirteen New York City hospitals participated; 805 surveys were examined from 99 nursing units (response rate 42%). Compared with nurses working 8-hour shifts, those working 12-hour shifts were on average more satisfied with their jobs, experienced less emotional exhaustion, 10 times more likely to be satisfied with schedules, 2 times as likely to perceive 12-hour schedules as important, and 58% less likely to report missing shifts; units with 12-hour shifts had lower vacancy rates and weeks to fill the position (all P values < or =0.05). There were no differences in patient outcomes. CONCLUSIONS: Nurses working 12-hour shifts were more satisfied. There were no differences in quality outcomes. Flexibility and choice in shift length are important elements in a positive nurse work environment. This study represents an innovative attempt by a labor-management bargaining group to make an evidence-based decision. We encourage others to conduct similar studies.     

The nurse executive: challenges for the 21st century

AIM: The aim of this paper is to examine the challenges facing the nurse executive in the 21st century by questioning the traditional attributions of leadership to the nurse executive role. BACKGROUND: Historically, the leadership role in nursing has been assumed by the nurse executive. The predominantly female character of nursing, however, has ensured that demonstrations of leadership amongst nurses have been infrequent and compatible with prevailing male-defined ideologies. Examples of this include career restructuring and educational reforms in Australia. FINDINGS: This paper found that the apparent lack of leadership in nursing was able to be traced back to early management theories which categorized leadership as a function of management. CONCLUSIONS: If nurses are to assume leadership positions in the health care system of the 21st century, nurse leaders will have to let go of traditional managerial practices and behaviours. In the emerging health care system of the new century, nurse executive practices will focus on achieving change rather than predictability in organizational outcomes.     

Work environment characteristics of high-quality home health agencies

This concurrent mixed-method study examines the nurse work environment of high-quality Medicare-certified home health agencies. High-quality (n=6) and low-quality (n=6) home health agencies were recruited using agency-level publicly reported patient outcomes. Direct care registered nurses (RNs) from each agency participated in a focus group and completed the Practice Environment Scale of the Nurse Work Index (PES-NWI). No significant differences were found in the PES-NWI results between nurses working in high- and low-quality agencies, though nurses in high-quality agencies scored higher on all subscales. Nurses working in all the high-quality agencies identified themes of adequate staffing, supportive managers, and team work. These themes were not consistently identified in low-quality agencies. Themes of supportive managers and team work are reflective of effective leadership at the manager level. Agencies struggling to improve quality of care might consider developing their managers' leadership skills.     

The impact of nursing work environments on patient safety outcomes: the mediating role of burnout/engagement

OBJECTIVE: To test a theoretical model of professional nurse work environments linking conditions for professional nursing practice to burnout and, subsequently, patient safety outcomes. BACKGROUND: The 2004 Institute of Medicine report raised serious concerns about the impact of hospital restructuring on nursing work environments and patient safety outcomes. Few studies have used a theoretical framework to study the nature of the relationships between nursing work environments and patient safety outcomes. METHODS: Hospital-based nurses in Canada (N = 8,597) completed measures of worklife (Practice Environment Scale of the Nursing Work Index), burnout (Maslach Burnout Inventory-Human Service Scale), and their report of frequency of adverse patient events. RESULTS: Structural equation modeling analysis supported an extension of Leiter and Laschinger's Nursing Worklife Model. Nursing leadership played a fundamental role in the quality of worklife regarding policy involvement, staffing levels, support for a nursing model of care (vs medical), and nurse/physician relationships. Staffing adequacy directly affected emotional exhaustion, and use of a nursing model of care had a direct effect on nurses' personal accomplishment. Both directly affected patient safety outcomes. CONCLUSIONS: The results suggest that patient safety outcomes are related to the quality of the nursing practice work environment and nursing leadership's role in changing the work environment to decrease nurse burnout.     

"Towering genius disdains a beaten path" Abraham Lincoln

We see nursing leadership existing at all levels in nursing...all nurses leading. Nurse executives within academic health environments across Canada will be influencing health policy directions and dialogue within the profession nationally. They will be contributing to the development of a national agenda for nursing practice, education, research and leadership. These nurse executives will lead in a way that makes an invigorating impact on human service in health care environments and they will be dedicated to preparing the nursing leaders of tomorrow. The Academy of Canadian Executive Nurses will connect with the Office of Nursing Policy, Canadian Nurses Association, Canadian Association of University Schools of Nursing, Association of Canadian Academic Health Care Organizations and others to develop position papers regarding key issues such as patient safety, health human resource planning and leadership in the Canadian health care system. Our definition of professional nursing practice, fully integrated with education and research, will be advanced through these endeavours. The end result of a strong individual and collective voice will be improved patient outcomes supported by professional nursing practice in positive practice environments. This paper is intended to stimulate dialogue among nursing leaders in Canada, dislodge us from a long and traditional path, and place us firmly in a new millennium of leadership for the profession and practice of nursing, a style of leadership that is needed, wanted and supported by nurses and the clients we serve. It is the responsibility of those of us who lead in academic health science centres to be courageous for the students we support, the puactitioners we lead and the renewal of the profession. We are the testing ground for nursing research, and need to be the source of innovation for nursing practice. It is incumbent on us to leap forward to engage a new vision of the professional practice of nursing with a reconfigured work design and work environment compatible with the new economy, workplace and workforce.     

Staff nurses lead the way for improvement to shared governance structure

The Magnet? model encompasses structural empowerment, transformational leadership, exemplary professional practice, and new knowledge, innovations, and improvements. As the American Nurses Credentialing Center reminds us, great leaders, structures, and nurses lead to great knowledge, innovation, and outcomes. One organization experienced the wisdom in this model through restructuring the systemwide staff nurse councils. The authors describe the steps by which this restructuring was accomplished and some of the positive effects on the work environment.     

The effect of structural empowerment and perceived organizational support on middle level nurse managers' role satisfaction

BACKGROUND: The restructuring of Canadian health care organizations during the past decade has reduced the visibility of nursing leadership. This has resulted in job conditions that have disempowered nurse managers and influenced their ability to create positive work environments, mentor potential nurse leaders, and gain satisfaction in the leadership role. These conditions threaten the retention of a cadre of high quality nurse leaders in today's chaotic health care setting. OBJECTIVE: The purpose of this study was to examine the relationship between structural empowerment and perceived organizational support and the effect of these factors on the role satisfaction of middle level nurse managers. METHOD: A secondary analysis was conducted as part of a larger study of 126 middle level nurse managers working in Canadian acute care hospitals, randomly selected from the Ontario provincial registry. Eighty-four nurse managers responded to a questionnaire mailed to their home addresses. RESULTS: Structural empowerment was positively associated with middle level nurse managers' perceived organizational support. The combination of empowerment and perceptions of organizational support were significant predictors of middle level nurse managers' role satisfaction. CONCLUSIONS: The findings support R.M. Kanter's (1977, 1993; Men and Women of the Corporation. Basic Books, New York) contention that empowering work conditions have an impact on employees' feelings of support and sense of accomplishment at work. Positive perceptions of organizational support may play an important role in retaining current middle managers, and possibly attracting future leaders to management positions.     

急诊科护士留职意愿与职业承诺、护士长领导方式的相关性

目的探讨急诊科护士留职意愿、职业承诺与护士长领导方式的现状及相关性。方法采用便利取样法选择广州市3所三级甲等综合医院130名急诊科护士进行问卷调查,了解急诊科护士留职意愿、职业承诺与护士长领导方式现状。结果急诊科护士留职意愿、职业承诺总分分别为（20．19±3．74）分、（76．16±12．13）分,均处于中等水平;急诊科护士长领导方式以变革型方式为主,职业承诺、护士长领导方式与护士留职意愿呈正相关（均P〈0．05）;护士急诊工作年限、情感承诺、规范承诺可作为预测急诊科护士留职意愿的主要因素（多重线性回归方程共解释护士留职意愿全部变异的38．7％）。结论急诊科护士留职意愿、职业承诺均处于中等水平;急诊科护士长以变革型领导方式为主;急诊护士工作年限、情感承诺、规范承诺是影响急诊护士留职意愿的主要因素。护理管理者应提高护士职业承诺水平,以提升急诊科护士的留职意愿,进而稳定护士队伍,有助于人才的健康发展。     

Finding the leader within: thoughts on leadership in nursing

Leadership is an important topic in nursing. We recognize the importance of leaders who represent us well to those outside of the profession, yet many nurses do not view themselves as "leaders." This is unfortunate, because real leadership is less about a title or institutionally granted power, and more about how we "show up" in the many situations that make up our days. The image of the nursing profession is formed in the many day-to-day interactions between nurses and patients, families, the public, physicians, and administrators. Nurses who can find their inner leader and use it in their practice, at whatever level of the organization they contribute, will find that they are able to positively impact patient care and outcomes. This paper describes a framework for finding your inner leader that is based upon 5 "skill-cepts" (skills derived from leadership concepts), which we have found essential to leading.     

Preoperative assessment of the surgical patient

Nurses play an important role in the preassessment of surgical patients. With the rise in free-standing surgical clinics and the move of many surgical procedures to office-based surgical clinics, quality patient care could be compromised. Preassessment of surgical patients in office-based and hospital clinics ensures quality patient care from the moment patients enter the office to when they are discharged from care. The process of preoperative evaluation is essential in assessing the medical condition of patients, evaluating their overall health status, determining risk factors, and educating them. Surgical preassessment benefits patients, physicians, and nurses by not only improving surgical outcomes and patient satisfaction but also ensuring patient safety. Nurses employed in office-based surgical suites require specialized knowledge and clinical skills to offer continued, well-informed care to their patients.