Vitello-Cicciu, Joan M. PhD, RN, FAAN, FAHA NEA-BC; Weatherford, Barbara PhD, RN; Gemme, Donna DNP, RN; Glass, Bonnell MS, RN; Seymour-Route, Paulette PhD, RN
Leadership development (LD) is a key component in achieving the goal of strong nursing-led presence and outcomes in the evolving healthcare system. The Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, recommended that nurses, nursing education programs, and nursing associations should prepare the workforce for leadership positions.1 The need for nursing LD emerged as a key initiative in the report noting that “strong leadership is critical if the vision of a transformed healthcare system is to be realized… the nursing profession must produce leaders throughout the healthcare system.”1(p1) Effective nursing leadership has been shown to increase nurse retention, engage nurses in the workplace, and enhance high-quality and safe patient outcomes.1
In 2011, the Organization of Nurse Leaders of Massachusetts and Rhode Island (ONL) initiated a leadership development program (LDP) in keeping with its mission of developing nurse leaders. ONL leaders reported a decrease in LDPs being offered from employers in the states. The goal of this program was to enhance LD in midlevel nursing leaders in both practice and education. The Leadership Academy (LA) addressed theory-based leadership content focused on the concept of self as leader, becoming a leader in relationship with others, and the leader within the organization.
The concept of self as leader, based on the American Organization of Nurse Executives (AONE) model,2 was the impetus for this study and was used with permission. The 1st learning module focused on self as leader and guided participants in identifying their own intrinsic leader characteristics, including personality types and traits. Then through self-reflection and self-awareness, participants could begin to apply these behaviors and enhance their ability to balance the dimensions of management and leadership, thus setting the stage for transformation of their leadership competencies through the LDP.2
This LDP was delivered in 4 sessions over a period of 8 weeks using concepts similar to those in the AONE Nurse Manager Leadership Partnership Learning Domain Framework and used with permission.2 Faculty for the LDP included nationally known leaders chosen from a pool of qualified applicants within the ONL membership. Faculty were selected based on leadership experience, academic credentials (doctoral preparation), content expertise, willingness to develop the coursework through the 1st 4 cycles, and a time commitment to participate, mentor, and evaluate the program. Teaching modalities included presentation of content, group activities, reflection, journaling, case studies, project development, coaching, and mentoring.
In addition to end of course evaluation, it was determined that a means of identifying behavioral changes in nursing leaders following an LDP was needed to sustain the program financially and assist nursing executives to justify sending their midlevel leaders to such a program. This level of program evaluation after LD initiatives is typically not reported.2
Review of Literature
There is currently a lack of research examining changes in leadership behaviors following attendance in an LDP as well as suitable instruments for measurement found in the literature.3-5 There is a growing body of literature linking critical leadership behaviors and traits to outcomes and establishing that these behaviors can be learned in educational programs.10 Black and Earnest’s3 theoretical model of leadership suggests that the context and experience of leaders result in behavior changes that ultimately should lead to transformation of the self, organization, and the community. Current theoretical focus on LD typically focuses content on self-awareness and self-reflection as key components.4
Kirkpatrick proposed a 4-level approach to educational evaluation.7 The 4 levels consist of reaction, learning, behavior, and results. Reaction, how the learners react to the process of learning, is typically measured in terms of how well the participant liked the program and is usually measured at the conclusion of the educational program. Learning considers the extent to which knowledge is gained, and behavior shows the capability to perform the learned skills on the job. Finally, results consider factors such as financial, operational efficiency, and turnover.6
Nursing leaders need to take an active role in influencing leadership outcomes by using all the levels of evaluation to demonstrate their impact on organizational improvement. In an era of cost containment in healthcare, it was felt that an exploration of changes in leadership behaviors following an LDP was well suited to guide this study.
Purpose of Study
The purpose of the study was to describe the self-reported changes in leadership behaviors of nursing leaders following attendance in an LDP. The research question guiding this study was: “What changes do nurse leaders describe in their leadership practice following participation in an LDP?” This descriptive qualitative study is guided by level 3 of Kirkpatrick’s framework focusing on behavioral changes as a result of attending an LDP.6 The use of qualitative descriptive methods in this study allows the complex narrative of participants to provide meaning to the changes in their leadership behaviors following an LDP.7
Site and Sample Participants
Participants for the study were recruited from the 1st 2 cohorts of 34 nursing leaders attending the LA from 2 New England states. E-mail invitations were sent to all nurse leaders in these cohorts, inviting them to participate in the study by attending a focus group session between 5 and 9 months after completion of the LDP. This time frame was chosen to allow for behavior change from the LDP to be integrated into practice. Three geographically convenient locations were used for the focus groups. Interested participants who were unable to attend the focus group sessions were invited to participate via an online survey using the focus group questions.
Data Collection and Analysis
In this phase of the study, qualitative data were collected from focus groups and online responses. Written consent was obtained prior to the beginning of each focus group. Demographic data consisted of age, sex, years in nursing, years in management, and years in current position. Online participants indicated consent by completing the focus group and demographic questions. The participants were asked to respond to 8 questions (Table 1) about the knowledge gained about self in the leadership role and 1 question about attending the focus group. The focus groups were audio taped using digital recording equipment, and other members of the research team made observation notes during the sessions. Recordings were transcribed by an independent transcriptionist and a code assigned to each participant for identification purposes and to maintain confidentiality. Data from the online surveys were downloaded as text files and analyzed in the same manner. This study was approved under expedited review by the institutional review board of the University of Massachusetts Dartmouth.
Participants’ responses were used to categorize the data for emerging themes about LD. Comments, specific quotes, and themes were weighed according to frequency of occurrence, specificity, emotion, and extensiveness.8 The coding of themes was initially done by 2 researchers, which revealed an extensive list of approximately 62 themes to capture all variables. Coding was reviewed for consistency and interrater reliability with all 5 researchers present. The entire researcher team then debriefed and reached consensus on the coding of themes identified from the focus groups. The next step involved collapsing these 62 themes into 7 broader ones to capture the majority of themes that were consistent with frequency and similarities (Table 2).
There were 34 eligible participants, 32 females and 2 males, invited to participate in focus groups or an online survey. Thirteen participants completed the study for a total response rate of 38%. All participants in the study were female, with an age range from 26 to 55 years. Total years in nursing ranged from 5 to 40 years with a mean of 21.2. The number of years in management ranged from 1 to 18 years with a mean of 7.4. The years in their current position ranged from 1 to 13 years with a mean of 3.7. The highest level of education for these 13 participants was BSN (6) followed by MSN (4) and DNP/PhD (3). The study group was a representative sample of the eligible participants in years of management experience and years in current position.
Thematic analysis revealed 7 themes related to leadership behavior changes on the job as articulated by the research participants. They consisted of articulating self-awareness through self-reflection, using self-regulation to manage one’s emotions, being emotionally aware of others, valuing of the Myers-Briggs Trait Inventory® (MBTI),9 seeking diverse feedback, engaging in active listening, and having crucial conversations. The following consist of examples of each theme from focus group participants.
Articulating Self-awareness Through Self-reflection
Leader C. stated how she became more aware of herself and how she changed her behavior by having a difficult conversation with another person: “I found myself… stopping to assess where I was going next with the conversation instead of getting emotional and reacting. I’ve adapted that take a deep breathe, take a minute or 2, whereas I think I was more of a reactor before.” Leader H. stated the following exemplifying her own self-reflection about trying to be like other leaders: “I think that what I have come to realize is that the work is infinite; it’s never done. So I think this content gave you a maturity to think about that and give yourself permission to say I can’t compete with her over there who comes in at 6 AM and leaves at 8 PM. There’s going to be a balance because I am only going to be the best I can be if there’s balance, and my family means a lot to me.”
Using Self-regulation to Manage One’s Emotions
Leader I. reflected on her own ability to identify her emotions and then regulate them: “Identifying emotions has always been a little bit of a difficult part for me because I tend to ignore them. It’s been a work in progress trying to identify my own emotions So, I am far more cognizant of them at this point, and sometimes they just are there and I know immediately, but sometimes I really still have to stop and think, well, how am I feeling about this, how am I reacting emotionally, and why am I, you know, there’s the why behind an action that comes from the emotion.”
Leader A. commented on how journaling has helped her with managing her own emotions. “…most of the things I am managing in my current role I can tend to be inflicting emotion upon which I really try not to do. I try to be even keeled with my response, and have it be continuous… but there are times where it can aggravate me or you know whatever the emotion is behind. And so like I said when I started, the journaling piece I think has really helped me take that emotion and put it somewhere else, get it out, and then be able to be much more even keeled and to have a response that is better for everyone involved….”
Being Emotionally Aware of Others
Leader G. reflected on an interaction whereby she gleaned some knowledge about another of her direct reports she became more aware of that person’s emotionality: “So, I have floor coordinators… one in particular… she’s passionate, but kind of think maybe sometimes she comes off all over the place, and really vocal about things, and I don’t feel like she listens sometimes. So, after we had our module on emotional intelligence, we actually talked about it. She actually came to me a couple of weeks ago and said ‘I have this class in emotional intelligence, and you really—like you really have a really high emotional intelligence.’ So we both have this mutual understanding that although I may not react the same way she reacts, or I may not react at all, it doesn’t mean I don’t care, and it doesn’t mean that I’m not hearing what she’s saying or hearing the intensity of the situation or what she perceives as really important. And it was just kind of a breakthrough, I guess with somebody who is there, who is really on that front line.”
Valuing the MBTI
Leader A. shared her reflection on knowledge gleaned from the MBTI9 explored during the module on leader as self: “And I refer back to that every once in a while because, and I’ll probably keep doing it to see kind of what my, you know, how I progress. But I think it’s how I feel right now, and so I’m going to kind of go back to those results and kind of see how I can tailor my style for what’s happening in my professional life right, now.”
Leader F. found as a result of the MBTI9 that she was not as detail oriented as she thought: “And so I realized that and I… when I’m making changes at the clinic with the nurses in their role, I realized what was causing some angst among them was that I wasn’t sharing the detail. I was giving a big picture, but they wanted the details and I realized that I thought I was saying that to them, but they were definitely weren’t getting what they wanted. I realize I need to plan things out a little bit better.”
Seeking Diverse Feedback
Leader H. shared a difficulty she was having with eliciting feedback from other members on a project: “I’m trying to be more inclusive. I thought I had rationalized about why I wasn’t being so inclusive which was… which is, you know, just wanting to get the work done. I’m definitely, like, I like closing the loop and having things done, and in the process of doing that I realized, you know, that I exclude people, and, you know, that to be a good leader just because a project might take longer if you actually include more people and think strategically about your plan, that’s okay.”
Engaging in Active Listening
Leader J. shared how she became more of an active listener with her staff about the Thanksgiving schedule: “And then I got everyone in the room, just kind of how we’re set up here, and listened to every single person’s thoughts around why they should work this day or not, or should Thanksgiving start the night before, you know, all the things that go down. I think that helps me because I was able to listen to all the points, and then as a leader, I took it over and incorporated all those different concerns that they were having so kind of bring the anxiety level down.”
Having Crucial Conversations
Leader M. in managing her emotions more effectively has learned the following about herself as a leader: “I think I learned that I need to step back and sometimes write things down before I have a conversation especially if it’s a difficult conversation or a conflicting conversation because it’s not one of my strong suits. So I really kind of try to validate it, that that’s an important strategy for me to do as a leader, and it helps me not be as kind of emotional with some of those difficult situations.
Leader B. spoke about an increase in self-confidence after the model on self. This self-confidence helped her to have a difficult conversation with a physician colleague who had ordered a very large dose of diazepam (Valium) for a patient whom she was nervous about: “So trying to take my confidence, trying you know to really build on those skills that I’ve had, but I don’t think I quite knew I had them until I went through the content on self. So trying to take those skills and really use them in those kind of conversations… so being able to go up to the intensivist who directed some of that care and have that conversation with him on a one-to-one. I’m worried so why aren’t you worried (about the patient). Why aren’t you worried about this? Help me understand why you’re not worried? So you know being able to have those conversations and being able to have that confidence in myself being able to pull out those… from my toolbox all those little tools to have that conversation is important. But knowing that about myself is important.”
Findings from this qualitative study are not generalizable outside the group of participants in these LDP sessions. We did not explore the impact of these behavioral changes on specific outcomes such as retention of employees, nurse satisfaction, or financial outcomes within these participants’ organizations.
Three of the researchers served as faculty in the LDP, although not in the session that addressed self as leader, and all 5 researchers were members in the professional organization sponsoring the LDP. Participant responses could have been influenced by the presence of faculty during the focus groups. In addition, the focus group process itself could have been influenced by individual members in the reporting of their experiences. These limitations were not apparent in the data analysis process as there was a wide range of responses and themes after initial coding by all 5 researchers.
Participants in this study were able to describe in detail their perceptions of changes in leadership behaviors as nursing leaders after attending an LDP. The themes that addressed their focus on the self as leader included articulating self-awareness through self-reflection, using self-regulation to manage one’s own emotions, being emotionally aware of others, and valuing the MBTI.9 Participants also described changes in their leadership behavior as evidenced by seeking diverse feedback, engaging in active listening, and having crucial conversations. This study illustrated that 1 group of nursing leaders who participated in an LDP was able to identify increased self-awareness as a leader and incorporate their learning into new leadership behavior within 6 to 9 months after completion of their program. The last phase of the evaluation process, level 4 of Kirkpatrick’s model, which addresses results, has been completed, and a manuscript is under development.
Senior nursing leaders in organizations face constant pressure to reduce costs, and allocating resources to LDPs can be difficult to maintain. These 7 changes in leadership behaviors as a result of attending an LDP clearly illustrate the impact that content focusing on the self as a leader can have on participants 6 to 9 months after LDPs. Leadership style in healthcare has been shown in other studies to impact various organizational outcomes such as work environment,10 intent to stay,11 and patient outcomes.12 However, it can be difficult to explain a direct, causal relationship between participation in an LDP and organizational outcomes. Moreover, the process of leadership is relationship based.13 Leading in complex organizations requires an evaluation method based on the everyday experience of participants giving voice to the complexities of leadership in today’s healthcare and academic settings.14 Further evaluation research is needed to test various models of LDP and to explain the relationship between participation in an LDP and leadership behavior changes that produce organizational and patient outcomes.