LEADERSHIP practices at all levels of the organization have been enumerated in a number of studies as important to the excellence and viability of clinical practice.1–3 While many levels of nursing leadership have been articulated with regard to their relationship to clinical practice, very little study of the role of the nurse executive and the leadership practices associated with that role has been broadly undertaken.4 Furthermore, issues of excellence and exemplary clinical performance have been identified as important to advancing the practice of nursing and improving healthcare services in hospitals across the United States.5–7 In recent years, exemplars associated with the Magnet Recognition Program in the United States have been identified as strong indicators of excellence.8 A number of the sources of evidence identified as performance elements in the Magnet Recognition Program specifically address leadership performance issues as critical to measures of nursing performance excellence in Magnet-recognized hospitals.8(p36) Specific enumerators of nurse executives' leadership are also identified in the required sources of evidence with regard to Magnet recognition.8(p37) In addition, chief nurse executive competencies have been identified as critical facilitators necessary to create an organizational context and as imperative for nursing practice and quality.8(p36) In today's healthcare work environment, excellence and innovation are interchangeable, each necessary to the others. Excellence implies that there is a continuous commitment to innovation. The continuity and continuous commitment to excellence is a commitment to innovating practice in a way that advances it and ultimately improves the patient experience. Magnet performance has suggested this connection through almost all of its sources of the evidence of excellence and of the commitment to practice innovation.9
CHIEF NURSE EXECUTIVE COMPETENCE
The chief nurse executive initiates the strategic imperative and supports and sustains the organizational and operational context facilitating high levels of clinical nursing excellence and innovation.10–12 For nursing practice to be supported and for nursing excellence/innovation to be sustained, nursing scholars have suggested that the chief nurse executive must demonstrate a strong sense of personal leadership, a clear commitment to advancing excellence and innovation in nursing practice, and the ability to create an environment in which practicing nurses can innovate and advance their clinical work.13–16 The problem for nursing organizations has been that it has not been explicit what the specific exemplars for nursing leadership excellence are and which leadership skills or practices lead to creating excellent and innovative hospitals.
The American Organization of Nurse Executives17 and Marquis and Huston18 posited that the leadership competency of the chief nurse executive is one of the most important factors influencing the context, culture, and care in nursing organizations. The chief nurse executive creates the framework for practice and provides the mandate and the infrastructure for excellence and innovation at every level of nursing practice.17 Marquis and Huston18 found that chief nurse executive leadership effectiveness has a powerful impact on the management success of other leaders in the nursing organization. The quality of nursing care provided was influenced by the ability of the chief nurse executive to create a safe and productive environment in which nurses can practice.19 Other studies4,7,20 showed that leadership practices of nurse executives impact the context and role of staff nurses; and along with relationship, these practices influence the effectiveness of patient-care decision making.
Specific to the role of the chief nurse executive, it is valuable to be clear regarding role-related competencies. As well, it is important to be clear about competencies specifically aligned with the role and perceived by chief nurse executives as valuable in the expression of the role. To further refine these perceptions and differentiate them within the context of specific enumerators of excellence and innovation, it may be valuable to distinguish the differences, if any, between chief nurse executives in Magnet hospitals and those in non-Magnet hospitals. The study reported here focused on providing a quantitative comparison by examining hospitals' chief nurse executives' self-perceptions of leadership practices.
STUDYING CHIEF NURSE EXECUTIVES' LEADERSHIP PRACTICES
The purpose of this quantitative quasi-experimental comparative research study was to examine hospitals' chief nurse executives' self-perceptions of leadership practices and compare self-perceptions of leadership practices in Magnet and non-Magnet hospitals in the United States by using the Leadership Practices Inventory.21 The dependent variables were the 5 Leadership Practices Inventory subscales (LPI-S). The independent variable was Magnet or non-Magnet hospital status. The focus was to determine whether a difference exists in the dependent variable (ie, leadership practices) between Magnet and non-Magnet hospitals, the independent variable (ie, Magnet or non-Magnet recognition). The design was to administer the LPI-S online to all 187 Magnet hospitals' chief nurse executives (187 at the time of the study) and a comparable random sample of non-Magnet hospitals' chief nurse executives and to examine the resultant data.
The dependent variable, LPI-S scores, was measured on a continuous scale with a theoretical range from 1 to 10. The scores were derived by calculating the average of questions related to each variable subscale: (1) modeling the way, (2) inspiring a shared vision, (3) challenging the process, (4) enabling others to act, and (5) encouraging the heart. Smaller scores indicated less of the variable attribute whereas larger scores indicated more of the variable attribute. The independent variable, hospital type, was measured on a dichotomous nominal scale. Hospitals were categorized as either Magnet or non-Magnet. Statistical analyses were performed using SPSS for Windows.22 The study sample was described using measures of central tendency (ie, mean and median) and dispersion (ie, standard deviation and range) for continuous/ordinal scaled variables and frequency and percent for categorical scaled variables. There were 5 hypotheses tested using 2-sample t tests, and the analyses were 2-sided with a 5% α level.23
The LPI-S instrument is divided into the 5 components (subscales): (1) model the way, (2) inspire a shared vision, (3) challenge the process, (4) enable others to act, and (5) encourage the heart.24 Elements of related transformational leadership practices were identified within each component. Using this instrument, leadership practices were self-assessed and quantified to determine the participants' perception of identified leadership actions, exemplifying a particular leadership practice.24 Because the LPI-S was based on contemporary transformational leadership principles and practices and had a long well-documented history of validity and reliability, it reflected expected exemplars of transformational leadership consistent with Magnet recognition.25–27 The LPI-S focused on practices, rather than on concepts, as a way of ensuring applications of leadership rather than that of demonstrating conceptual understanding.28
Chief nurse executives at all Magnet hospitals and a random sample of the same number from non-Magnet hospitals were invited to participate in the study. A random sample of non-Magnet hospitals listed in the American Hospital Association's (AHA's) AHA Guide29 containing data from all American-accredited hospitals was utilized. The random sample was selected from the bed size categories as defined by the AHA Guide so that a roughly equal number of Magnet and non-Magnet hospitals of each bed size could be obtained. Random response rates prevented assurance of an absolute one-to-one matching. The final sample contained hospitals in each AHA bed size group.
The random sampling occurred following Magnet hospital data collection to ensure as close a match between Magnet and non-Magnet hospitals as possible. Maturation and history effects on the data were minimized by the data collection time frame of less than 1 month between Magnet hospital data collection and non-Magnet hospital data collection. Study instrument site linkage and informed consent information were forwarded to each respondent through online e-mail. The instrument was completed online at the Web site SurveyMonkey.com. Each participant completed an informed consent form before participating in the study. Online survey instruments included an affirmation of consent. Three biweekly reminders were forwarded to participants to encourage completion of the instrument. Upon completion of data collection, statistical methods were applied to the data for reporting and interpretation.
The study sample was described using measures of central tendency (mean and median) and dispersion (standard deviation and range) for continuous/ordinal scaled variables and frequency and percent for categorical scaled variables. Because this study sought to compare the average of the continuous measurement (the LPI-S score) between 2 independent groups, the 2-sample t test was appropriate. Hypotheses 1 through 5 (related to the LPI-S subscales) were tested using 2-sample t tests, and the analyses were 2-sided, with a 5% α level. Because this researcher did not know which hospital type (Magnet or non-Magnet) would have the larger LPI-S score, a 2-sided t test was applied. Two-sided t tests were selected to allow for the possibility that either the Magnet or the non-Magnet hospitals could have larger average LPI-S scores.23
The dependent variables were the 5 LPI-S scores. Modeling the way, inspiring a shared vision, challenging the process, enabling others to act, and encouraging the heart scores were measured on continuous scale with a theoretical range from 1 to 10. The score was derived by calculating the average of the questions associated with the related subscale. Smaller scores indicated less of the leadership practices attribute, whereas larger scores indicated more of the attribute.
The independent variable for this analysis was hospital type (Magnet and non-Magnet). Magnet and non-Magnet status was measured on a dichotomous nominal scale. Hospitals were categorized by bed size and region and type (Magnet or non-Magnet).
The results were configured in 3 main categories. The first section detailed the demographic data related to the participants in the study. The second section focused on detailed statistics obtained from the study as they relate to the research questions. The final section is a summary of the data analysis.
There were 161 chief nurse executives who participated in the study. Ninety (56%) were chief nurse executives of non-Magnet hospitals, and 71 (44%) were chief nurse executives of Magnet hospitals (Table 1).
The most common job titles were chief nursing officer (39.1%) and vice president (26.1%). The remaining 45% included a wide range of titles for the chief nurse executives. One of the lowest percentages (4.3%) was that of the title of chief nurse executive.
Table 2 shows hospital size, as measured by number of beds, ranging from less than 100 to more than 500 beds. The most common size was of those with 100 to 299 beds (35.4%). Those hospitals above 500 beds comprised the next largest number (26.7%), followed by hospitals with 300 to 499 beds (19.9%) and hospitals below 100 beds (18%).
Chief nurse executives from 39 states participated in this study. Illinois represented the largest number of participants (5.6%). Florida followed with 7 hospitals (4.3%). At least 1 Magnet and 1 non-Magnet chief nurse executive from each state having Magnet-recognized hospitals at the time of this study participated (39 states). All 10 federal hospital regions were represented by Magnet and non-Magnet hospitals' chief nurse executive participants.
Aggregate self-perception mean scores
In reviewing the average scores for the leadership practice categories, participants' average scores were high in all categories. The aggregated mean score for modeling the way was 8.8064, for inspiring a shared vision was 8.5079, for challenging the process was 8.4994, for enabling others to act was 9.1673, and for encouraging the heart was 8.6106. The range for all participants in the leadership practice of modeling the way was a low mean score of 6.83 and a high mean score of 10.00; inspiring a shared vision had a low mean score of 5.50 and a high mean score of 10.00; challenging the process provided a low mean score of 5.40 and a high mean score of 10.00; enabling others to act elicited a low mean score of 6.40 and a high mean score of 10.00; and the fifth leadership practice category, encouraging the heart, produced a low mean score of 4.00 and a high mean score of 10.00 (Table 3).
DATA ANALYSIS RESULTS
After statistical application and analysis were completed, the following data were generated. The average and standard deviation (SD) modeling the way score was 8.77 (0.69) versus 8.86 (0.66) for the non-Magnet and Magnet hospitals, respectively; t = −0.84, df = 159, P = .40. Because the P value resulting from the 2-tailed t test was not less than .05 (5%), the null hypothesis was not rejected, indicating that there was no statistically significant difference in the average modeling the way score between non-Magnet and Magnet hospitals' chief nurse executives' self-perception of leadership practices.
The average (SD) inspiring a shared vision score was 8.41 (1.02) for the non-Magnet hospitals' chief nurse executives versus 8.63 (0.77) for the Magnet hospitals' chief nurse executives; t = −1.55, df = 159, P = .12. Because the P value resulting from the 2-tailed t test was greater than .05 (5%), the null hypothesis was not rejected and it was concluded that there was no difference in the average inspiring a shared vision score between the leadership practices self-perception of non-Magnet and that of Magnet hospitals' chief nurse executives.
The average and standard deviation (SD) challenging the process score was 8.41 (0.90) versus 8.61 (0.79) for the non-Magnet and Magnet hospitals' chief nurse executives, respectively; t = −1.47, df = 159, P = .14. The P value resulting from the 2-tailed t test was greater than .05 (5%); thus, the null hypothesis was not rejected, and it was concluded that there was no difference in the average challenging the process score between non-Magnet and Magnet hospitals' chief nurse executives' self-perception of their leadership practices.
The average (SD) enabling others to act score was 9.17 (0.61) versus 9.16 (0.53) for the non-Magnet and Magnet hospitals' chief nurse executives, respectively; t = 0.067, df = 159, P = .95. Thus, the null hypothesis was not rejected, with a P value greater than .05 (5%), and it was concluded that there was no difference in the average enabling others to act score between non-Magnet and Magnet hospitals' chief nurse executives' self-perception of their leadership practices.
The average (SD) encouraging the heart score was 8.53 (1.07) versus 8.71 (0.76) for the non-Magnet and Magnet hospitals' chief nurse executives, respectively; t = −1.20, df = 159, P = .23. The P value was greater than .05; thus, the null hypothesis was not rejected, and it was concluded that there was no difference in the average encouraging the heart score between non-Magnet and Magnet hospitals' chief nurse executives' self-perceptions of their leadership practices (Table 4).
The results indicate that although Magnet chief nurse executives' scores were generally higher, there was no statistically significant difference in the self-perceptions of leadership practices of chief nurse executives in Magnet and non-Magnet hospitals.
Based on the data analysis, 3 major conclusions can be drawn:
1. There is no significant difference in chief nurse executives' self-perceptions of leadership practices in Magnet and non-Magnet hospitals.
2. Chief nurse executives indicate high mean score values in self-perceptions of leadership practices in both Magnet and non-Magnet hospitals.
3. Obtaining Magnet excellence is not related to the self-perceptions of chief nurse executives' leadership practices.
The results of this study suggest that chief nurse executives value these transformational leadership practices in the perception of their roles comparably, regardless of whether or not they are affiliated with Magnet hospitals. Magnet recognition does not appear to affect the intensity or level of self-perception or the value of these leadership practices in chief nurse executives' responses. Because the same level of self-perception of leadership practices exists between Magnet and non-Magnet chief nurse executives, it appears that Magnet excellence cannot be directly related to chief nurse executives' self-perceptions of leadership practices and that such practices do not directly influence the achievement of Magnet recognition. This self-valuing of the leadership practices of chief nurse executives supports the value attached to the role by the standards-setting bodies17,30,31 and the value that researchers have attached to nurse executives' leadership in creating the context for exemplary clinical practice18,19,32 even though it was not specifically differentiated in Magnet hospitals.4,27
This study of chief nurse executives' leadership practices in both Magnet and non-Magnet hospitals provides data that may lead to a broader frame of study of the role of chief nurse executives in relationship to the pursuit of excellence, innovation, and/or Magnet recognition. Including a focus on other's perceptions of the leadership practices of chief nurse executives and further relating the role to specific measures of excellence and/or innovation may be helpful in establishing precise skills or attributes that more directly relate to the pursuit of excellence. It is important to note that the high-level scores of all participants in this study indicate that all nurse executives attach importance to these effective leadership practices. In consideration of the growing need for innovation (as well as excellence), the demonstration of these skills will become increasingly important. The growing emphasis on creating an innovative context for the pursuit of change and excellence will be critical over the next decade. Whether the nurse executive works to achieve Magnet excellence or not, the pursuit of change and the creation of a culture of innovation will certainly not be an option for the foreseeable future.
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