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Nursing Management:
doi: 10.1097/01.NUMA.0000437773.56144.c3
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EXECUTIVE EXTRA: Leadership at 360°

Reistroffer, Cindy MBA, BSN, RN, NEA-BC; VanDriel, MaryKay EdD, RN, FACHE; Barry, Jean PhD, RN, NEA-BC

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Author Information

Cindy Reistroffer is the director of Network Engagement at Priority Health in Grand Rapids, Mich. MaryKay VanDriel is the president of Value Health Partners in Grand Rapids, Mich. Jean Barry is an associate professor at Kirkhof College of Nursing, Grand Valley State University, in Grand Rapids, Mich.

The authors have disclosed that they have no financial relationships related to this article.

Multiple competing priorities are placed on nursing leaders in today's healthcare environment, and they must know how to engage their workforce to effectively manage these demands. Engagement is defined as a persistent, positive state of being in which an employee experiences fulfillment in his or her job.1 Studies within the last decade have demonstrated a direct link between leadership performance and staff work engagement. For example, in a qualitative study of 20 RNs, poor relationships within the management team had a negative effect on the levels of staff work engagement.1 Another study found that effective leaders who possessed honesty, integrity, and high ethical standards had a positive impact on leader-direct report relationships.2

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One of the defining characteristics of being part of a team is interdependence among team members.3 When team members are interdependent, conflict management strategies must be in place and utilized. This is especially important when the team is composed of key leaders because of the influence these individuals have on the overall functioning of the organization.4 When conflicts arise and remain unresolved within the leadership team, the work environment may become tense and staff may feel unsafe. This may then negatively affect staff engagement levels.1 Given that work engagement is associated with improved workplace performance and better staff retention, nurse leaders must be skillful in communication, coaching, and conflict management strategies.5

We describe the use of a nontraditional leadership development process that included an open 360-degree feedback process, along with other experiential learning activities, to address leader and employee engagement.6 The team members involved were the leaders of a Women's and Infants Services department in a Midwest, nonprofit, acute care academic hospital that delivers more than 7,400 births annually. The department also provides care to other inpatient services, such as those handling high-risk OB-GYN surgical patients. All 17 members of the team, with the exception of an administrative assistant, were RN leaders with titles of director, manager, supervisor, clinical nurse specialist, educator, project manager, or RN quality specialist.

When this professional development process began in 2011, the nurse leadership team was well established, with members averaging 11 years (range 0.5 to 24 years) in their leadership roles. Rather than focusing on employees directly, these leaders chose to focus on themselves and their effectiveness as a team. This professional development effort was triggered after one leader stated that she “didn't feel comfortable speaking up.” It quickly became apparent that team members suffered from ineffective communication, poor peer support, unproductive conflict management, and a lack of mutual understanding.

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What's open 360-degree feedback?

Corporate settings have utilized 360-degree evaluations for years, but this type of evaluation has only recently been seen in the healthcare environment.7 In the corporate setting, 360-degree evaluations are typically anonymous, or closed, where the participant receives a printed summary feedback report and, perhaps, individual coaching regarding the results. However, in an open 360-degree feedback process, face-to-face conversations take place, with participants offering and accepting feedback directly. Unlike the closed 360-degree feedback process, participants benefit from understanding the effect of their interpersonal skills and leadership behaviors immediately. The group engages in a discussion regarding the individual's characteristics and the influence he or she has on the team, including whether it's viewed as positive or negative.6

This open method was chosen to quickly and effectively drive change within the leadership team. Individual and team development has been known to be more useful among managers when feedback is received during a workshop rather than in paper reports.8 A combination of 360-degree feedback and facilitated coaching tactics enhances self-awareness and behavioral management.9 It's intended to improve leaders' capabilities and their pursuit of learning goals over time as they act on the development items suggested by the feedback they receive.10

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The development process

The leadership development process began with a 2-day retreat, followed by year-long intermittent coaching focused on individual and team action planning. With the assistance of a facilitator, this work was championed, but not owned, by the director of the department. The retreat days were designed to create an experiential workshop milieu that would transform team members' perspectives, motivations, skills, and behaviors. They were to identify their strengths and weaknesses, and learn to leverage each other's performance through coaching and guided team-building exercises.

To begin, the department director and facilitator decided on a two-pronged approach: (1) incorporate team exercises to create and maintain a psychologically safe environment where risk would be minimized and trust established, and (2) engage the team in open and honest dialog.6 Before the retreat began, team members were asked to complete a management tool and were given their results.11

To stress the importance of leaders taking risks, the facilitator used a comfort zone diagram and the Johari Window as models of reference. Both were intended to help the leaders understand different ways of thinking about themselves, their team, and team dynamics. The comfort zone diagram gave the leaders a framework for identifying three psychological zones (“comfort,” “stretch,” or “panic”) where they do their best work and most often spend their time. The Johari Window was introduced as a graphic model of interpersonal awareness—a method for enhancing the “public” self while minimizing the “blind,” “private,” and “unknown” selves.12 The team collectively engaged in a conversation to answer the question, “Whose responsibility is it to disclose and offer feedback?” This led the members to acknowledge their personal responsibility for disclosure and feedback within the team. After this, the facilitator asked all of the leaders to engage in the open 360-degree feedback process.

The goal was to help team members maximize their public selves by being open to their peers' feedback and offering honest feedback to their colleagues. There was initial apprehension within the team. However, the facilitator offered reassurance that no one would be put on the spot and described how the process would enhance individual awareness and positively influence the team's performance. The facilitator explained the process in depth, indicating that each person would take a turn to openly identify each leader's strengths and weaknesses and how these characteristics influenced the team's performance. Initial ground rules were set to ensure a high-level, professional, respectful dialog focused on individual and/or team performance. The facilitator then asked for a volunteer.

The department director knew in advance that it was crucial for her to volunteer first because this was a critical moment in the group process. By going first, the director set the tone for the process and became a role model for what would be expected of all participants. The director took time to reinforce to the team why she felt this work was important. Giving the team permission to speak openly and honestly, and reinforcing that their words would be accepted as “gifts,” helped further ease the tension among the team members. At this point, the group eagerly talked first about the director's strengths. Then the facilitator guided them through a discussion of the director's weaknesses and how they affected the team's performance.

After the process was completed for the director, the facilitator asked for the next volunteer; this continued until feedback was shared with each member of the team. There was no documentation, although all members wrote down their own lists of strengths, weaknesses, and team impact. This was done to reduce fear, reinforce the high degree of confidentiality, and affirm that this work was only for personal/professional growth.

The second retreat day was held 10 days later, allowing the participants time and space to process the information they had received earlier. The focus for day 2 was on team performance, the team's style, and its culture. The team members' management tool results were used by the facilitator to help them understand their interpersonal styles, value their differences, and learn how to deal with conflict constructively and improve their performance.

With a better understanding of the group culture, team members realized why they found some peers easy to relate to and others more challenging. They also saw that collectively the team represented all four primary management styles and that this variety could be a significant asset. By the end of the day, the leaders understood that they needed to learn how to fully capitalize on each other's strengths and support each other's weaknesses to enhance the team's performance.

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Postretreat development

With the retreat completed, the leaders wanted to create and uphold healthy, sustainable team performance. They did this throughout the year by investing in both nonfacilitated and facilitated peer coaching. For example, a leader who was told that she came across as “abrasive” in her communication style often informally sought feedback from a peer whose communication style was gentler. Facilitated peer coaching occurred at monthly leadership meetings, and time on the agenda was proactively allocated. Team members used role play and the feedback processes they had learned during the retreat to identify effective communication and problem-solving strategies for current work issues.

Career development planning and goal setting were also part of the ongoing process: both individual and team goals were identified. The leaders had one-on-one discussions with the department director annually, ensuring that appropriate plans were in place, feedback was considered, and progress was made. Team goal setting was accomplished by asking all participants to identify their top three areas of focus. The team then collectively negotiated which goals were priorities for the year, what tactics would be used, and who was accountable for which actions.

Finally, after experiencing individual and team growth themselves, the leaders took it upon themselves to engage their direct reports. They focused on key employee leaders, such as charge nurses and shared governance chairpersons. To create an environment that embraced healthy, respectful communication at all levels within the department, they redesigned their monthly meetings to leave time on the agenda to discuss tough situations, answer any questions their teams might have, and engage in dialog. Charge nurses were asked to participate in the management tool survey and engage in group learning about the different interpersonal styles. In addition, the managers/supervisors helped their respective teams enhance their professionalism by coaching each charge nurse in the design of a career development plan.

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The team's response

Six months after the 2-day retreat, an online survey was administered to the leaders. The purpose was to (1) identify how they felt about their working relationships before and after the leadership development process, and (2) gather their perceptions of the effect that the process had on the team. This voluntary survey was structured to ensure anonymity and assess both qualitative and quantitative measures. The survey consisted of nine questions: two with a 5-point Likert scale and seven that were open-ended. (See supplemental content on the Nursing Management iPad app.)

To analyze the qualitative data, a thematic approach was used by three nonparticipating reviewers in addition to the department director. After they defined and categorized themes individually, they met to discuss and construct a master list of themes. The overarching themes that emerged were accountability, delivery, and publicity. Accountability was defined as being called on and accountable for—to be answerable.

The second theme, delivery, was defined as the method and manner in which people spoke and participated in the process. It was mentioned many times that it was harder to provide feedback than receive it. The manner in which this exchange occurred had a profound impact on the participants and, as a result, they were deeply touched by their peer group.

The third theme was the publicity of the feedback, defined as not private, open to all, and well known. Although the information was shared with only 17 people in a confidential setting, the somewhat public process propelled the leaders to want to change. The public nature of others knowing individual strengths and weaknesses hugely affected the participants, and they could no longer deny or contest what was said. The majority of the leaders' comments indicated that the information they heard wasn't new to them. However, the reality of how it affected them and their peers was new. It was heard with a deeper sense of value.

Overall, team members indicated that the component of the process that had the greatest effect was witnessing the vulnerability of themselves and their colleagues as they processed honest, caring feedback. The leadership development process was viewed as a pivotal moment that deepened relationships and generated trust at a higher level. The opportunity to digest the information, ask clarifying questions, and understand the message was paramount. Participants made numerous comments about the value of the process because it gave the leadership team clues for working together more effectively.

The quantitative results of the 6-month survey showed dramatic movement regarding communication after the open 360-degree feedback process compared with before the retreat. The average overall rating for “open and direct communication” increased from 2.76 to 3.87 on the 5-point Likert scale, resulting in a 40% improvement. (See supplemental content on the Nursing Management iPad app.)

In addition to the survey, all 17 members were asked to rate their perception of the team's health on a 1 to 10 scale, with 1 being “poor” and 10 being “excellent.” During the retreat, each team member was asked to identify an initial numerical value on a confidential note card. These were averaged and then compared throughout the year, with the process repeated on subsequent leadership development days. The initial average score was 5.84. Within 12 months, the team's average health assessment score increased to 7.73. Eighteen months after the initial retreat, the score increased to 8.41—a 44% improvement perceived by the team members.

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Implications for the field

By May 2013, following the completion of the second year of this leadership development process, the leadership team showed substantial growth in specific Gallup survey categories. Percentiles moved from the 40th to 50th in 2010 to the 70th to 80th in 2013. (See supplemental content on the Nursing Management iPad app.) In the “overall satisfaction” category, the leadership team experienced an inverted V profile, going from the 60th percentile in 2010, to the 90th percentile in 2011, and back to the 60th percentile in May 2013. This may be explain by a heightened peer comparison group because the mean score also improved during this period, as well as the timing or “honeymoon” phase of professional development.

In the same May 2013 timeframe, the Women's and Infants Services department achieved its highest scores in employee engagement, according to a Gallup survey.13 The most recent data showed the largest change for employees: all five categories improved, moving from the 10th to 30th percentiles in 2010 to the 30th to 40th percentiles in 2013. (See supplemental content on the Nursing Management iPad app.) Although there's no statistical evidence establishing a direct correlation between the leadership development intervention and these employee engagement scores, this anecdotal evidence points in that direction.

During and after this leadership development process, a positive shift was seen in both leadership and employee engagement. Based on previous work and a review of the literature, it appears that leaders who are fully engaged will have the capability and influence to engage other stakeholders, such as caregivers.14 Our engagement scores showed a domino effect, with leaders' overall satisfaction with communication improving by 40% the first year and employee engagement incrementally increasing during both the first and second years. Approximately 18 months later, we saw the largest improvement in employee engagement. Perhaps the team's greater effectiveness in dealing with conflict—both within the leadership team itself and with the nursing staff members they influence—created a more engaging environment. This particular development process ultimately harnessed the strengths of our leadership team.

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Lessons learned

Four major lessons were learned by the leadership team during this professional development process:

* Participation and engagement are critical to success. Despite the fact that the participants openly admitted they felt “out of their comfort zone” and blatantly stated “it was tough to go through,” they all felt it was an opportunity that couldn't be achieved any other way.

* The pace of change depends on the individual. In any professional development effort, the leader must remember that each participant will advance at his or her own pace.

* Support and training are crucial. All participants concluded that it was harder to find the right words when offering feedback as opposed to hearing feedback themselves. Professional and peer coaching should be considered in conjunction with any 360-degree feedback process so participants feel that they're communicating effectively.

* Follow-up action plans and one-on-one conversations are essential to sustain team performance. This reinforces the continuation of the hard work already completed and promotes ongoing behavior change management.

Leadership development, specifically the open 360-degree feedback process, set the stage for a dynamic group of leaders who have a high potential to engage and lead themselves and their colleagues in creating a trusting environment. Early evaluation indicates that this process has positively influenced our leadership and employee engagement. However, efforts to continue this growth and level of engagement must be embraced and nurtured to ultimately meet the competing priorities experienced by nurses.

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© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. All world rights reserved.

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