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Journal of Nursing Administration:
doi: 10.1097/NNA.0b013e3181d40f65

Listening to Nursing Leaders: Using National Database of Nursing Quality Indicators Data to Study Excellence in Nursing Leadership

Anderson, Barbara Jo MSN, RN, NE-BC; Manno, Martin MSN, RN, ACNS-BC; O'Connor, Pricilla PhD, RN; Gallagher, Eileen MSN, RN

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Author Information

Authors' Affiliations: Clinical Director (Ms Anderson), Director Nursing Education and Research (Mr Manno), Penn Presbyterian Medical Center, Philadelphia; Research Consultant (Dr O'Connor), Nurse Educator (Ms Gallagher), Pennsylvania Hospital, Philadelphia.

Corresponding author: Ms Anderson, Penn Presbyterian Medical Center, 51 N 39th St, Philadelphia, PA 19104 (

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There are varying and overlapping leadership characteristics that exemplify excellence in nursing leadership. To assess aspects of leadership that helps create a healthy work environment that supports nurses' provision of quality care at the bedside, the authors used a national survey instrument to examine the characteristics of nurse managers identified as excellent nurse leaders by their staff. The authors discuss their findings and a proposed theoretical model to explain specific nursing leadership characteristics that support staff nurse job satisfaction and retention.

The study of the quality and characteristics of nursing leadership has been a focus of the management literature and research over the last several years. Much of the interest lies in what makes successful nurse mangers with particular emphasis on their role as the chief retention officer. Marquis and Huston1 suggest that job satisfaction is the best antidote to burnout. They also suggest that the attitude and energy level of managers directly affect the attitude and productivity of their employees.1(p457)

Certainly from an organizational point of view, retention of staff provides the experience necessary to provide quality care in an increasingly complex environment. In addition, a stable workforce reduces the costs associated with recruitment, orientation, and training. No complex modern business would survive if they had to start over with a new workforce every 1 to 2 years.

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Literature Review

Anthony et al2 enumerated characteristics and behaviors attributed to successful nurse managers. These included communication, advocating for nurses, providing a supportive organizational culture, autonomous practice environment, scheduling, staffing, continuing education, and collaborative relationships. In their study, focus groups of voluntary participants divided by educational preparation were asked questions about how they see the role of the nurse manager. Questions included the following: What are the key roles of the nurse manager? What skills do nurse managers need to retain staff? To what extent do you believe most managers have those skills?

The study results were compiled into 3 categories: structure, process, and outcome. The structure components included professional areas such as role modeling, coaching/mentoring, hiring/recruiting, and fiscal responsibilities such as budgeting and payroll. The process components included listening, conflict resolution, and communication. The outcome category had quality care, patient satisfaction, and keeping stakeholders happy. Anthony et al2 concluded with a reference to servant leadership as the new paradigm of nursing leadership. That is, the new nurse leader serves his/her employees who in turn serve the customer.

Servant leadership is often applied to nursing management. A study by Neill and Saunders3 described 10 principles of servant leadership observed in nursing practice. These included listening, empathy, healing relationships, awareness, persuasion, conceptualization, foresight, stewardship, commitment to growth or being people builders, and building community. Neill and Saunders3 emphasize the servant leadership principles of empathy, awareness, and persuasion as key in regard to nursing leadership. Empathy, the second principle, is the quality of striving to understand the position and circumstance of others. Awareness and persuasion are the fourth and fifth principles of servant leadership and are used as strategies to find the best path to shared decision making.

Laschinger et al,4 in their article entitled "Context Matters: The Impact of Unit Leadership and Empowerment on Nurses' Organizational Commitment," reported a survey of 3,156 staff nurses in 217 hospitals examining unit-level leader-member exchange quality and structural empowerment and its link to nurses' psychological empowerment and organizational commitment. They postulate that understanding factors that promote staff nurse commitment will inform others in their efforts to recruit and retain nurses. They found unit-level leader-member exchange quality had a significant direct and indirect effect on nurses' psychological empowerment and a statistically significant direct and indirect effect of job commitment.

A survey of RNs by Ulrich et al5 examined the workplace environment. The response rate for the random survey was 53% for a return of 1,783 completed questionnaires. Sixty-five percent of the respondents practiced in direct patient care positions. Answers of interest to our research study were the questions surrounding the quality of relationships in the workplace. Only 42% of the RNs reported the relationship between nurses and nurse managers as excellent or very good. In addition, they found a significant relationship between nurse-to-nurse manager relationships and job satisfaction. Sixty-four percent of the respondents said that more respect from frontline managers would cause them to reconsider leaving their current position. In this study, the primary indicator of respect was that managers involved the nurses in the process of making key decisions that affect nurses' ability to provide patient care. In regard to recognition for accomplishments, the respondents rated their organization excellent 5%, very good 17%, and good 29%. Respondents were also asked if their organization had increased efforts at nurse recognition in a deliberate effort to improve retention. Only 31% of the nurses responding felt that their organization had made such efforts.

Dunham-Taylor6 studied nursing leadership using a qualitative and quantitative cross-sectional survey of exceptional nurse executives and their staff nurses. Their results suggest that the most effective leaders have characteristics from both transformational and transactional management styles. The nurse leaders receiving the highest staff scores were identified as being highly motivated, optimistic, and energetic. The overall characteristic of these leaders was balance between their personal and professional life. Other themes were striving to improve, humility, and a willingness to make decisions. These nurse leaders stressed the importance of communication, respecting and valuing other's contributions, and having a clear vision.

In a study of the qualities of nurse manager leadership that supports a culture of retention, Manion7 interviewed 26 nurse managers whose units had low turnover, low vacancy, high staff and patient satisfaction, and good patient outcomes. To validate her findings, she also held 3 focus groups of staff from the units studied and 3 focus groups of the direct supervisors of the interviewed nurse managers. The interviews developed 5 themes of excellent nursing leadership.

Manion's7 first theme is putting the staff first. This is demonstrated by treating the staff with respect. It also includes listening and responding to their needs. The second theme involves forging authentic connections. Knowing the staff and creating a sense of community were part of this aspect of the excellent nurse leader. The third area was to coach for and expect competence. Part of this aspect, also cited by other researchers and considered an important component of Magnet organizations, is to support professional development. The fourth area for nurse managers who were successful "chief retention officers" was their ability to focus on results. This area included empowering and involving staff. The final theme that developed from the qualitative analysis was partnering with staff. In this area, Manion7 points to visibility as being crucial for these successful nurse managers. It was important to these managers not to just be seen on their units but to be jumping in and helping out whenever possible. Other key aspects of partnering with staff were accessibility and open communication.

Authentic leadership is 1 of the 6 standards identified by the AACN as necessary to the creation of a healthy work environment. Shirey8 addresses the concept of authentic leaders in her work. She identifies the nurse manager as integral to creating the work environment but goes on to say "few specific guidelines are available on how to create and sustain the critical elements of a healthy work environment."8(p256) The other components identified by the AACN are skilled communication, true collaboration, effective decision making, appropriate staffing, and meaningful recognition.

The relationship of staff nurse job satisfaction and nursing leadership is often discussed in practice. Upenieks9 used both a qualitative and a quantitative design to study whether job satisfaction was interlinked with leadership effectiveness as demonstrated by the nurse administrator, directors, and managers and compared these aspects in Magnet and non-Magnet hospitals. The nurses in the Magnet facilities reported chief nurse executives as quite visible. Upenieks9 reported that the greatest difference in individual item quantitative scores between Magnet and non-Magnet hospitals was the way they rated leadership accessibility and responsiveness. Most nurse leaders in Upenieks'9 study felt today's nurses valued leadership visibility. However, Upenieks9 goes on to say that the differences in the job satisfaction scores reported can be explained by the "gap between the nurse leader's actual visibility and responsiveness within the organization and his/her mere statement of the importance of these traits."9(p94) Nurse executives in Magnet hospitals were reported to be more visible by their directors and managers than were those nurse executives in non-Magnet hospitals.

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Study Design

With the expansive literature on what makes a good leader, it is often difficult to know where to begin in a process to promote leadership excellence. At our organization, we had the opportunity to participate in the National Database of Nursing Quality Indicators (NDNQI) RN survey. We used the results of the survey to investigate the qualities of managers who were seen as leaders by their staff. Nurse managers who scored above the mean on the nursing leadership component of the job satisfaction scale were asked to participate in a focus group exploring the qualities they viewed as significant to their leadership success.

Penn Presbyterian Medical Center (PPMC) is a 300-bed, acute-care teaching hospital located in Philadelphia, Pennsylvania, and is part of the University of Pennsylvania Health System. The nursing department participated in the NDNQI RN survey in October 2008. The survey had 696 participating hospitals, with a total of 14,738 nursing units reporting. Penn Presbyterian Medical Center had 99% survey participation, with 11 inpatient units and the emergency department reporting data. Five nurse managers met the qualifications for inclusion in the study.

The study was approved by the University of Pennsylvania institutional review board as an exempt study. The 5 qualified nurse managers were asked to participate in a study involving the NDNQI data. They signed consent to have the interviews taped and transcribed for subsequent analysis. The participants were informed that the information collected would be blinded for review by the researchers to ensure anonymity and that, after transcription, the audiotape would be destroyed. The participants were informed they were being invited to participate in a research study to explore nursing leadership characteristics. However, they were not told the results of their individual NDNQI scores until the beginning of the focus group.

Once assembled for the focus group, the participants were informed they had exceeded the mean for their clinical area in the leadership category of the job satisfaction component of the NDNQI RN survey. The participants were told the purpose of the study was to determine what they felt was the reason for their success. Similar to Manion,7 we selected nurse managers identified as exceptional and used induction to arrive at key elements of successful leadership.

Prior to the start of the discussion, the principal investigator (B.J.A.) gave each participant an index card and asked him/her to write in 1 or 2 words why he/she felt he/she achieved this rating from his/her staff. All participants were able to quickly provide their responses. The cards were collected, and the principal investigator (B.J.A.) left the room.

The focus group was facilitated by a coinvestigator (M.M.) and a graduate nursing student (E.G.). The coinvestigator (M.M.) is the director of Nursing Education and Research at PPMC and is viewed as neutral by the nurse managers. Brief introductions were made, and confidentiality was reiterated. The graduate nursing student (E.G.) observed the focus group and took notes that would later support transcription and interpretation of the codes. The coinvestigator read probing questions to the participants (Figure 1), which was then followed by open discussion. Once discussion ceased, the coinvestigator read the question once more and asked if there was anything else the participants wanted to add. If there were no further comments, the coinvestigator moved on to the next question.

Figure 1
Figure 1
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Data Analysis

After transcription, the study team consisting of the primary investigator, coinvestigator, a graduate nursing student, and a consultant PhD nurse researcher analyzed and coded the data independently. Subsequently, a meeting of the team was held to determine the first level coding of the data. For a code to be considered, 3 of the 4 team members had to agree. The codes were then collapsed to reduce any vague and overlapping expressions of the participants. Finally, the team aggregated the codes into theoretical constructs as presented in Figure 2. The codes and theoretical constructs were reviewed at a special meeting with the participants for confirmability of the information.

Figure 2
Figure 2
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The results of the key elements that the participants wrote on their index cards are presented in Figure 3. All participants reported visibility as a key component of their leadership and was a major theme of the coding (Figure 2). Several of the direct quotes, which support this included: "I think visibility is a key thing"; "…just be visible and also communication"; "Visibility too I think, I try to come in on the off-shifts on a weekend even for an hour or two just to have them see you…." Visibility as an aspect of nursing leadership is reported in other studies including Manion's7 work cited earlier.

Figure 3
Figure 3
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Communication was written on the index cards by 3 of the 5 participants and was also a major theme of the coding (Figure 2). Supporting quotes were as follows: "So it is a lot of communication and a lot of rounding from my perspective"; "It is candid feedback, a candid discussion, and we do it together." Our findings also grouped under the umbrella of communication the qualities of appreciation and recognition and the role of mediator. These qualities are also reflected in the following direct quotes: "At the end of the day, I just say thank you"; "…For example, I will go in and say you are doing a really nice job with that and make sure that it is not just the individual but the whole team."

Communication was one of the process components reported in the study by Anthony et al.2 Upenieks'9 study in Magnet versus non-Magnet hospitals also concluded that key work empowerment structures such as emphasis on professional autonomy, respect for professional nursing practice, and systematic communication between clinical nurses and the leadership team support nursing job satisfaction.

The elements of visibility and communication form the core of our analysis. In addition, the overlay of values is critical to the success of either of the elements. By this, we mean that visibility and communication must be linked to the values piece to be effective. Neill and Saunders3 discussed servant leadership as it may influence nursing leadership. The idea of servant leadership was a concept in our coding. Of particular importance were the components of empathy and listening. Laschinger et al4 found that unit-level leader-member exchange quality effected the job commitment of staff nurses. Our analysis also implied that visibility and communication needed a quality component to be effective. The key elements to that quality component are best encapsulated as respect and empathy. Several direct quotes that relate respect and empathy include "I always try to tell the staff we are going to make mistakes, if we don't make mistakes, then we are actually lying because I expect mistakes, and that's the only way we are going to get better"; "It [mistakes] can happen to anybody and it is a great reminder"; "Do I expect you to take 7 patients no, because I wouldn't be able to do it, and I don't expect you to do it, and they know that I make mistakes too, and I admit that." These elements are supported in much of the literature and in particular the themes developed by Manion.7

In pulling together the themes of the study, we postulate the Nursing Leadership Values Model presented in Figure 4. This model represents the critical nursing leadership characteristics of visibility and communication and the values of respect and empathy, which inform them. It is this interaction that is the foundation for staff nurse job satisfaction and retention.

Figure 4
Figure 4
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Force10 reviewed the literature on nurse manager leadership styles and concluded by saying that "effective nurse leaders have also earned integrity through seniority, technical skill, and continuous support and visibility in the clinical environment."10(p340) She further states that providing leadership education that promotes visibility and responsiveness to staff should be a key strategy to affect nurse turnover. If we are to create a healthy work environment, retain nurses, and provide quality care to patients, then we must focus on our leadership with consideration of these aspects. Shirey8 points out that as the stress in complex organizations increases, the "soft" side of leadership becomes more important. The fiduciary aspects of management are not diminished in importance by emphasizing the importance of the messenger and the delivery. However, the qualitative characteristics of nursing leadership do influence staff nurse job satisfaction and patient outcomes. Based on this study, nursing administrators are recommended to focus leadership techniques to incorporate the key elements of visibility and communication with the values of respect and empathy to foster success in their organizations. As one of the study participants stated, "I am here for my staff, and that is just how I see my role." The Nursing Leadership Values Model implemented through servant leadership may not only assist in creating a healthy work environment but also promote organizational transformation that is positive and sustainable.

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1. Marquis BL, Huston CJ. Leadership Roles and Management Functions in Nursing: Theory and Application. Philadelphia, PA: Lippincott Williams &Wilkins; 2006.

2. Anthony MK, Standing TS, Glick J, et al. Leadership and nurse retention: the pivotal role of nurse managers. J Nurs Adm. 2005;35(3):146-154.

3. Neill MW, Saunders NS. Servant leadership: enhancing quality of care and staff satisfaction. J Nurs Adm. 2008;38(9):395-400.

4. Laschinger HK, Finegan J, Wilk P. Context matters: the impact of unit leadership and empowerment on nurses' organizational commitment. J Nurs Adm. 2009;39(5):228-235.

5. Ulrich BT, Buerhaus PI, Donelan K, et al. How RNs view the work environment: results of a national survey of registered nurses. J Nurs Adm. 2005;35(9):389-396.

6. Dunham-Taylor J. Identifying the best in nurse executive leadership, part II: interview results. J Nurs Adm. 1995;25(7/8):24-31.

7. Manion J. Nurture a culture of retention. Nurs Manag. 2004;35(4):29-39.

8. Shirey MR. Authentic leaders creating healthy work environments for nursing practice. Am J Crit Care. 2006;15(3):256-267.

9. Upenieks VV. The interrelationship of organizational characteristics of Magnet hospitals, nursing leadership, and nursing job satisfaction. Health Care Manag. 2003;22(2):83-98.

10. Force MV. The relationship between effective nurse managers and nursing retention. J Nurs Adm. 2005;35(7/8):336-341.

© 2010 Lippincott Williams & Wilkins, Inc.