Impact of clinical leadership development on the clinical leader, nursing team and care-giving process: a case study

Aim This study explored the dynamics related to a leadership development programme and their impact on the clinical leader, the nursing team and the care‐giving process. Background While there is a growing conviction about the need to invest in transformational leadership in nursing, further insight into the true complexity of leadership development and, more specifically, how leadership can make a difference in nursing and patient outcomes is essential. Method A single instrumental case study was conducted in a unit of a large academic hospital where a Clinical Leadership development Project (CLP) was implemented successfully. We used mixed methods with multiple sources of data to capture the complexity of leadership development. Data were collected through individual interviews, focus groups and observation of participants. A purposive sample of 17 participants representing a wide variety of team members has permitted data saturation. The data were categorized and conceptualized and finally organized into a framework describing leadership development on the unit and its impact on the leader, the nursing team and the care‐giving process. Results Leadership development is an ongoing, interactive process between the clinical leader and the co‐workers. The head nurse became more effective in areas of self‐awareness, communication skills, performance and vision. The nursing team benefited because more effective leadership promoted effective communication, greater responsibility, empowerment and job clarity. Improved clinical leadership seemed also to influence patient‐centred communication, continuity of care and interdisciplinary collaboration. Conclusions The results of the study give more insight into the processes underlying the leader’s progress towards attaining a transformational leadership style and its impact on the team members. The impact of leadership on the care‐giving process, however, remains difficult to describe. Implications for nursing management The interactive nature of leadership development makes CLP a challenge for the leader as well for the team members. Through its impact on the leader and the nursing team, CLP is a valuable instrument for improving work environments of nurses, contributing positively to patient‐centred care.     

The mediating effects of team and self-efficacy on the relationship between transformational leadership,and job satisfaction and psychological well-being in healthcare professionals: A cross-sectional questionnaire survey

BackgroundThe importance of transformational leadership for the health and well-being of staff in the healthcare sector is increasingly acknowledged, however, there is less knowledge about the mechanisms that may explain the links between transformational leaders and employee health and well-being.ObjectivesTo examine two possible psychological mechanisms that link transformational leadership behaviours to employee job satisfaction and well-being.DesignCross-sectional study design.SettingsThe study took place in two elderly care centers in large Danish local government. Staff were predominantly healthcare assistants but also nurses and other healthcare-related professions participated in the study.Participants274 elderly care employees completed the questionnaire. Surveys were sent to all employees working at the centers. 91% were female, the average age was 45 years.MethodsA questionnaire was distributed to all members of staff in the elderly care centers and where employees were asked to rate their line manager's leadership style and were asked to evaluate their own level of self-efficacy as well as the level of efficacy in their team (team efficacy) and their job satisfaction and psychological well-being.ResultsBoth team and self-efficacy were found to act as mediators, however, their effects differed. Self-efficacy was found to fully mediate the relationship between transformational leadership and well-being and team efficacy was found to partially mediate the relationship between transformational leadership and job satisfaction and fully mediate the relationship between transformational leadership and well-being.ConclusionsWithin the pressurised environment faced by employees in the healthcare sector today transformational leaders may help ensure employees’ job satisfaction and psychological well-being. They do so through the establishment of a sense of being in control as individuals but also as being part of a competent group.     

Promoting leadership: the development of a nurse executive team in an acute hospital trust

Aim The purpose of this study was to evaluate how an executive nursing team, within an acute hospital trust in the south of England, developed their leadership characteristics through the use of a professional development programme. Background This paper offers an insight into how this team worked together to clarify their views of their new role and how the role would be enacted. Method A questionnaire using quantitative and qualitative measures was used to explore the group’s leadership style and evaluate the professional development programme. Findings The findings show how the development programme worked and what clarity it afforded the group in terms of their leadership style. Group work, building on the findings, helped them define their particular characteristics, skills and leadership ability and what further work was needed to demonstrate this. Conclusions The issues raised, such as team‐working, mutual purpose and personal development, are discussed in terms of their function within an integrated executive team with vision and goals. Implications for nursing management In ensuring that the nursing service has positive purpose, direction and goals, there needs to be a strategic approach to corporate development; otherwise, nursing will struggle to lead itself within a fast changing health care system.     

Kenya and distance education: A model to advance graduate nursing

Africa is faced with a myriad of challenges, such as HIV/AIDS, malaria, tuberculosis, and a variety of political and historical complications that have affected the educational system for advanced nursing practice. In Kenya, the current situation in the higher education sector does not give nurses an opportunity to pursue graduate education after they have acquired the basic diploma in nursing due to limited government support and the type of education system existing in the country today. Although distance education has been available in Kenya for professionals such as teachers, in public universities, this kind of opportunity is unreachable for nurses who are working and need to further their education. Nurses desire to have access to advanced practice education to equip them with the relevant knowledge to cope and address the complex health issues arising in the management and care of patients. A collaborative model is presented as a potential solution for this need. Four major constituents are identified including hospitals and agencies, communities of interest, Kenyan universities and international education partners. Each has a part to play including contributions to information, communication of opinion and expertise, money and support, infrastructure and in-kind resources. Distance education is cost-effective and will help in building capacity at various levels of nursing including leadership in clinical practice, teaching, administration and research.     

Challenges and leadership strategies for managers of nurse practitioners

AIM: The aim of this paper is to report on the findings from our research into the recent introduction of nurse practitioners in Alberta, Canada. Through an organizational research perspective, we identify the critical role of health care managers in developing a sustainable nurse practitioner role. BACKGROUND: Previous literature has focused on nurse practitioners themselves as the key factor in their integration into the health care system. Although they are qualified and organizationally well placed, managers of nurse practitioners have been overlooked as a critical part of implementation strategies. KEY ISSUES: We interviewed 25 nurse practitioners and seven of their managers. Through our data analysis we identified three major challenges for managers: (1) clarifying the reallocation of tasks; (2) managing altered working relationships within the team; (3) continuing to manage the team in an evolving situation. Associated with these challenges, we propose leadership strategies that managers may find useful as they work through the consequences of introducing the nurse practitioner role. These strategies are: * encourage all team members to sort out 'who does what'; * ensure that task reallocation preserves job motivating properties; * give consideration to how tasks have been allocated when issues identified as 'personal conflict' arise; * pay attention to all perspectives of the working relationships within the team; * facilitate positive relationships between team members; * lead from a 'balcony' perspective; * work with the team to develop goals that are not over focused on the nurse practitioner; * regularly share with other managers the experiences and lessons learned in introducing nurse practitioners. CONCLUSION: For managers to be most effective, they need to address three challenges that are of a managerial, not clinical, nature. By implementing specific leadership strategies, managers of nurse practitioners can facilitate the introduction of the new role and improve its sustainability in health organizations.     

Partnering to Lead Change: Nurses’ Role in the Redesign of Health Care

Health care has a long-held perception of perioperative nurses as providers who advocate for patients and who carry out physician orders. According to the Institute of Medicine’s 2010 report on the future of nursing, not only must that view evolve, but nurses also must play a leading role, in partnership with physicians and other health care colleagues, if health care reform is to succeed. Several factors will prepare nurses for this new role of partnering to advance health, including advancing their formal education, developing leadership as a core competency, acquiring leadership skills, and being active in new models of leadership (ie, mentorship, volunteering, advocacy).     

Meeting a primary care challenge in the United States: chronic illness care

Leading health care experts in the United States have stated that the greatest primary care challenge today is meeting the complex needs of patients with chronic illness/long-term conditions or impairment.To address this challenge, there is a need for health care system redesign that requires a multidisciplinary team approach, including active participation from professional nurses. In particular, it is essential for advanced practice nurses to provide leadership in health systems design for which they are specifically trained and experienced. In this article, the primary care challenge related to chronic illness care management is addressed. Future implications for community-based, chronic illness care delivery and the education of future health care providers with a focus on advanced practice nurses will also be discussed.     

Interdisciplinary team leadership: a revisionist approach for an old problem?

Understanding of interdisciplinary teamwork is evolving. During health care restructuring, leaders across organizations have challenging responsibilities when work groups must integrate changing organizational values with new modes of service delivery. In this environment, a well-functioning interdisciplinary team in which clinicians work as member-leaders has the potential to further organizational change and foster improvements in patient outcomes. In this paper it is argued that the term interdisciplinary team leadership should be embraced cautiously as it may be a revisionist approach to an old problem, namely a means to modify existing theories of leadership that have been vague and continue to be poorly understood despite considerable effort to explicate knowledge over several decades. Preliminary research suggests that interdisciplinary team leadership is a model of shared leadership that requires more development if it is to become the cornerstone of interdisciplinary team practice in a radically reforming health sector. Stewardship is proposed as a potential philosophy for interdisciplinary team leadership, and a new, shared leadership role of practice leader is suggested.     

Expanding roles of Aboriginal health workers in the primary care setting: seeking recognition

The work of Aboriginal health workers (AHWs) in the primary care setting is discussed, emphasising that partnership with non-Indigenous health providers such as nurses and general practitioners brings complementary skills together to improve the health care available to Aboriginal clients, and to decrease the cultural and communication barriers to delivering such health care.The diverse skills and responsibilities of AHWs, which include clinical, health promotion, education and leadership roles, are illustrated.The current focus on increasing AHW educational opportunities, and the need to recognise AHWs as core health professionals and equal members of the health care team is presented. The increasing recognition of the role of AHWs in providing cultural mentorship for non-Indigenous colleagues is discussed.     

Expanding roles of Aboriginal health workers in the primary care setting: seeking recognition

The work of Aboriginal health workers (AHWs) in the primary care setting is discussed, emphasising that partnership with non-Indigenous health providers such as nurses and general practitioners brings complementary skills together to improve the health care available to Aboriginal clients, and to decrease the cultural and communication barriers to delivering such health care.The diverse skills and responsibilities of AHWs, which include clinical, health promotion, education and leadership roles, are illustrated.The current focus on increasing AHW educational opportunities, and the need to recognise AHWs as core health professionals and equal members of the health care team is presented. The increasing recognition of the role of AHWs in providing cultural mentorship for non-Indigenous colleagues is discussed.     

Burnout in Psychiatric Nursing: Examining the Interplay of Autonomy,Leadership Style,and Depressive Symptoms

It is important to consider ways in which nurses can be protected from experiencing the effects of burnout. This study examined the relationships between leadership style of psychiatric nurse supervisors, work role autonomy, and psychological distress in relation to psychiatric nurse burnout. Eighty-nine psychiatric nurses from Montana and New York hospitals completed an online survey that assessed their work-related experiences. Overall, results of this study indicate that the participants were experiencing high levels of emotional exhaustion and depersonalization when compared to a normative sample of mental health workers. Results also showed that leadership style and work role autonomy are likely to be environmental factors that protect against burnout in nurses. Finally, it was shown that the relationship between depressive symptoms and the burnout component of personal accomplishment may be influenced by nurses’ perceptions of the leadership style in their work environment. These findings are important because nurse supervisor leadership styles and amount of autonomy are characteristics of the work environment that may be amenable to change through training and intervention.     

Facilitators and barriers in implementing clinical nursing assessment in mental health care for older people: A multimethod approach

With the aging of the population and the growing prevalence of dementia, specialized and collaborative nursing care is paramount in this area. To ensure better quality care, it is necessary to use effective and context‐specific processes to implement evidence‐based practices and more specifically clinical nursing assessment. This study aimed to identify and describe factors that may influence the implementation of clinical nursing assessment in mental health care for older people. The Consolidated Framework for Implementation Research was employed to guide evaluation in the pre‐implementation phase in the specific context of mental health care for older people. Using a multimethod approach, interviews, focus groups, and a quantitative survey were conducted with a non‐probability convenience sample. A total of 39 hospital nurses (registered nurses and head nurses) were interviewed. Analysis yielded five main factors, notably three barriers and two facilitators. Barriers include a lack of general nursing culture, deficiencies in leadership, and difficulties in communication and collaboration. Facilitators comprise team cohesion and the perceived benefits of the study.     

The dual roles of rural midwives: the potential for role conflict and impact on retention

Nurses and midwives continue to make up the largest proportion of the health workforce. As a result, shortages of nurses and midwives have a significant impact on the delivery of effective health care. Shortages of nurses and midwives are known to be more pronounced in rural and remote areas where recruitment and retention remain problematic. However, rural nurses are often required to be multi-skilled, which has led to expectations that nurses who are also midwives, are required to work across areas of the hospital to help to address shortages. For midwives this issue is even more problematic as they may actually end up spending a very small percentage of their working day involved in the delivery of maternity care. This workforce strategy has the potential to seriously erode the skills of the midwives. Situations such as this are implicated in attrition of midwives because of the role stress that results when they are required to work in models of care where they experience the constant pull to work between departments and across roles. This paper addresses the requirement for midwives in some rural facilities to work across roles of general nurse and midwife and outlines the issues that arise as a result. In particular, the paper links the concepts of Role Theory to the requirement for midwives to work in dual roles and the potential for role stress to develop.     

Nursing leadership competencies: Low-fidelity simulation as a teaching strategy

Nurses must demonstrate leadership and followership competencies within complex adaptive team environments to ensure patient and staff safety, effective use of resources, and an adaptive health care system. These competencies are demonstrated through the use of communication strategies that are embedded within a relational practice. Health care professionals, regardless of formal position, need to assert their opinions and perspectives using a communication style that demonstrates value of all team members in open discussions about quality patient care, appropriate access, and stewardship. Challenges to effective communication and relational practice are the individual and organizational patterns of behavior, and the subsequent impact that these behaviors have on others. Students articulate situational awareness when they conduct a critical analysis of individual, team, and organizational functioning, and then use this information and evidence gained from a critical literature review to develop recommendations to improve individual, team, and/or organizational performance. Leadership and followership simulation exercises, inclusive of public feedback and debriefing, are used as a pedagogical/andragogical strategy in a nursing baccalaureate senior leadership course to facilitate learning of team communication skills and improve situational awareness. We view this strategy as an alternative to traditional classroom learning activities which provide little opportunity for recursive learning.     

Supporting newly hired nurses: a program to increase knowledge and confidence while fostering relationships among the team

BACKGROUND. It is important for newly hired nurses to be supported throughout their first year of employment by nurse leaders on their team. Newly hired nurses struggle with application of new clinical skills and critical thinking skills as well as integrating into unit culture. PROGRAM DESIGN. The Post Orientation Education Program (POEP) provided 18 newly hired nurses with clinical knowledge and support through one‐on‐one meetings with the nurse leaders on their unit. The nurse leaders discussed common diagnoses, laboratory tests, and medications in addition to providing support to the newly hired nurses as they adapted to the newness of nursing. Early in their career the newly hired nurses developed relationships with the leadership team that may have taken longer if not for the POEP. The program gave the newly hired nurses an opportunity to experience different teaching styles of the nurse leaders and offered them the chance to engage in conversations about both clinical and nonclinical information. OUTCOMES. The program was evaluated through pre/post tests and written evaluations. Evaluations revealed increased knowledge about common diagnoses, increased confidence in role, and the development of trusting relationships with the leadership team. CONCLUSION. The newly hired nurses valued the time that they spent with the leadership team as it helped them to integrate into the unit and feel comfortable using the leaders as resources for patient care. The POEP proved to be a program that impacted not only relationships among the team, but it increased retention and quality of patient care as the nurses felt supported by the team, knowledgeable about the care they were delivering and confident in their ability to seek out resources. A program like the POEP could be adapted to various healthcare settings based on individual needs of the team.     

The impact of a three-tiered model of nursing redeployment during the COVID-19 pandemic: A cross-sectional study

ObjectiveThe COVID-19 pandemic resulted in extreme system pressures, requiring redeployment of nurses to intensive care units. We aimed to assess the impacts of a 3-tiered pandemic surge model on nurses working in intensive care units during the COVID-19 pandemic.MethodologyIn this cross-sectional study, 931 nurses (464 intensive care and 467 redeployed nurses) who worked within four adult units in Western Canada during pandemic surge(s) were invited via email to participate in a survey. The survey explored the impact of redeployment, rapid unit orientations, just-in-time training, and the 3-tiered model of nursing during pandemic surge. Burnout was measured utilizing the Copenhagen Burnout Inventory questionnaire.ResultsA total of 191 survey responses were retained (59 intensive care nurses and 132 redeployed). Survey results are reported by tier, with outcomes varying based on team leadership, intensive care unit, and redeployment nursing roles. Burnout in personal and workplace domains was present amongst all nursing tiers, while only team leadership roles experienced burnout in the patient domain. Overall, team leadership roles and permanent intensive care nurses experienced the highest rates of burnout. Redeployed nurses reported numerous aids to success including support from colleagues, prior experience, and educational supports. Skill-based orientation, ongoing education, optimized scheduling, role clarity, and mitigators of psychological impacts were identified by respondents as potential facilitators of redeployment and surge models.ConclusionNurses working within this tiered model experienced high degrees of burnout, with highest prevalence amongst team leads and intensive care nurses. Optimization of support for and interventions aimed at improving well-being are important considerations going forward.Implications for clinical practiceTargeted strategies are required to support education, role transition, and optimize competency and role clarity during nursing redeployment for overcapacity surge. Essential strategies to support redeployed nurses include individualized competency assessments pre-redeployment and prior to role transitions, pairing redeployed nurses with the same intensive care nurse consistently, and availability of a nurse educator or resource for additional just-in-time training supports. Contingency disaster strategies should also include interventions targeting staff wellness and prevention of burnout, as well as identify scenarios in which redeployment may increase risks of psychological harm. Debriefing and peer-to-peer support models may increase the efficiency of psychological support for nurses, though additional research is required. Lastly, given enaction of tiered models of nursing care is largely a novel occurrence in the intensive care unit, leadership training is required to support frontline nurses taking on supervisory roles within these team models.     

Changes in community nursing in Australia: 1995-2000

AIM: This paper reports a study whose aim was to examine the congruence between community nurses' perceptions and the realities of changes in their work. BACKGROUND: There have been increasing challenges to the delivery of community nursing services in Australia over the past decade. Acute care sector changes and the recent focus on health promotion, prevention, early identification and intervention adds pressure and creates tensions for community nurses, which are well-documented in the literature. There is, however, a lack of empirical evidence of actual changes in community nurses' workloads and the focus of their work. Validation of nurses' perceptions would enable them to have a stronger voice in the future development of community health care. METHODS: Four sources of data were used: community health client administrative data 1995-2000; occasions of service data 1995-2000; staffing numbers 1998-2001; and interviews with 14 community nurses in late 2001. RESULTS: Documentary evidence shows that there has been a large increase in the number of adult clients, and all clients are increasingly receiving a shorter, more intensive, clinically focussed service and are then discharged from care, rather than receiving a lower intensity service over a longer period of time. Staffing numbers have not increased to match this higher acuity and intensity. These changes were echoed by the nurses, who reported that expanded acute care roles were impacting on their workload and resulting in a loss of holistic primary health care focus. There has been a lack of leadership and proactive planning by community nurses in response to these changes. CONCLUSION: Community health care in Australia is shifting from primary to short-term clinical care. Greater opportunities for community nurses to engage proactively in defining and promoting their role in the health care system are needed in order to ensure an appropriate balance of acute clinical and holistic primary health care in the community.     

Nursing attrition and the work environment in South African health facilities

A number of media reports appeared on the shortages of professional health workers in the public health sector. Unsatisfactory working conditions in health facilities were mentioned as one of the key aspects responsible for the shortages. Literature indicates that stress caused by unsatisfactory work environments may play a major role in employees' decision to resign their jobs, in spite of enjoying the nature of their work. The aim of this article is to explore the current human resource situation in nursing i.e. to determine if a shortage of nursing skills exists, to establish the challenges that nurses have to face in performing their duties and to establish the potential effect of the work environment on attrition. Currently 155 484 nurses are practicing in South Africa at a rate of 343 nurses per 100 000 of the population, which compares favourably with the World Health Organisation minimum of 200:100 000. The lack of reliable data on the supply of and demand for nurses makes it difficult to determine whether real shortages exist. However the supply of nursing services is influenced by the uneven distribution of skills across regions and the outflow of professional skills. It seems that the existing situation will deteriorate because fewer people are interested in taking up or pursuing nursing as a career in South Africa. At the same time a need for more nurses was identified because of the growth in the population as well as a change in health care needs. Workplace conditions for health workers employed at hospitals and clinics in South Africa were explored as part of a recent national study on the impact of HIV/AIDS on the health sector. Health workers' opinions on aspects such as workload, staff morale and working hours were obtained during personal interviews, which were conducted at 222 health facilities. Nine hundred and twenty four professional nurses, enrolled nurses and nursing assistants, who were mostly employed in the public health sector, participated. A stressful work environment was identified in public hospitals and clinics. An increase in the number of patients visiting these facilities, accompanied by a lack of equipment, unsatisfactory work environment and a shortage of nurses were pointed out. Many patients cannot be accommodated elsewhere because of a lack of finance and alternative health care options. Nurses also indicated that they do not get much support from their employers. The effect of all these factors culminates in a stressed workforce who may be forced to consider alternative career options. This will be to the detriment of health care in the country.     

Leadership: improving the quality of patient care

The satisfaction staff achieve from their work is in part determined by the style of management they work under. This article analyses the impact of a proactive leadership style on team performance and the quality of patient care.