Today’s healthcare environment demands that nurse leaders develop their own professional identity while implementing evidence-based outcomes in conjunction with developing, supporting, and assisting staff in the delivery of quality safe patient care (Westphal, 2012). Witges and Scanlan (2014) noted that staff nurses promoted to frontline nurse leader (FLNL) positions often lack professional development in management and leadership, which is crucial when supervising and leading nursing teams that drive positive patient outcomes. Although the responsibilities and skills of nurse managers are expanding in this complex healthcare environment, professional development for them is essentially nonexistent (Lefton, 2010). FLNL developmental training is essential for driving improvements and achieving staff satisfaction, healthy work environments, and cohesive teams, as well as improving patient engagement and reducing nurse sensitive indicators. Transitioning to the nurse leader role involves a steep learning curve, and new FLNLs often get caught up in performing the tasks of managing while overlooking their roles of developing staff and improving patient care (Sherman, 2013). New FLNLs do not routinely receive formal education in leadership, organizational culture, or systems management, and many have made the transition from staff nurse to their present position through a process of painful trial and error (Spencer, Al-Sadoon, Hemmings, Jackson, & Mulligan, 2014). Although most facilities have structured new staff nurse orientation, very few have an organized FLNL’s orientation, and there is no formal transition process from staff nurse to FLNL (Doria, 2015). Unless management and leadership skills are valued by all healthcare leaders, the quality of patient care and nursing satisfaction will remain stagnant or deteriorate (Kerridge, 2013).
Simply giving a nurse the title of manager does not make FLNLs proficient in the role (Kerridge, 2013). The healthcare environment, which is often frenetic and unpredictable, known as as permanent white water (Govier & Nash, 2009), and nurse leaders are often put in positions of doing things they have little experience in or have never done (Westphal, 2012). Govier and Nash (2009) further identified that navigating permanent white water successfully begins with effective leadership development.
Building and sustaining healthy work environments has proven challenging in today’s turbulent environment, and nurse leaders need to be competent to manage change (Sherman & Pross, 2010). Janes (2008) proposed that nurse leaders’ leadership development would improve healthcare services and patient outcomes. Spence Laschinger and Leiter (2006) found that the quality of the nursing practice environment is related to patient safety outcomes and patient safety is molded by nursing leadership. Lefton (2010) identified competencies essential to FLNLs beyond the managerial functions of staffing and managing of day-to-day functions, including building cohesive teams, improving staff through developmental coaching, and successfully communicating the organizational mission and goals to the staff. Spencer et al. (2014) note that FLNLs should have the knowledge, skills, and abilities to provide support, mentoring, and professional socialization to staff, assess their own attitudes and behaviors to develop a culture of feedback including praise and validation, recognizing good work, and managing difficult conversations. Developmental training is essential in driving improvements in staff satisfaction as well as patient satisfaction and outcomes.
PURPOSE OF THE PROJECT
In today’s ever-evolving healthcare environment, FLNLs are expected to be expert clinicians as well as leaders, and this expertise cannot solely come from on-the-job-training. It is unknown if FLNLs who have been oriented with only on-the-job-training are competent and if a professional development program will improve their competencies and confidence, patient outcomes, practice outcomes, and nursing satisfaction benchmarks. The purpose of this project was to measure the self-assessed Nurse Manager Leadership Partnership (NMLP) competencies of nurse managers, as identified through American Organization of Nurse Executives (AONE, 2016) and American Association of Critical-Care Nurses (AACN) Nurse Manager Inventory Tool (NMIT; AONE & AACN, 2008). These competencies cover areas such as finance, human resources and leadership, performance improvement, foundational thinking skills, technology, strategic management, clinical practice, relationship management, influencing behaviors, diversity, shared decision-making, personal and professional accountability, career planning, personal journey discipline, and reflective practice reference behaviors/tenets. The program assessments are evaluated through pretests prior to beginning the leadership development curriculum. At the conclusion of the curriculum, the posttests are given.
The author’s conceptual model (see Figure 1) predicts that FLNLs who attend the professional development program grounded in evidence-based curriculum will become adept at utilizing various leadership styles in the full-range leadership theory (FRLT), including laissez-faire, transactional, and transformational. As the FLNL becomes increasingly proficient in NMLP identified competencies, advancing toward expert, they become more adept at using styles of FRLT, applying at appropriate times.
This quasi-experimental project was conducted with two cohorts of participants who completed the competency inventory tool, pre- and postprogram attendance. A quasi-experimental design was chosen due to the lack of the experimental design of randomly assigned groups. The participants acted as their own controls. Of a potential pool of 100 FLNLs at the facility, 38 were recommended by the facility’s leadership to participate. Pre- and postsurvey collection allowed for self-assessed competency by participants in the intervention. The NMLP’s evidence-based practice framework was chosen for this project, and the correlating NMIT survey was administered on the first and last days of class. Individual variables were years of nursing experience, years of experience as an FLNL, and highest level of nursing education.
LEADERSHIP CURRICULUM PROGRAM
The intervention in this project was an evidence-based leadership curriculum in which participants attended 12 four-hour classes. The participants attained contact hours for attending the program, which aligned with the Nurse Manager Learning Domain Framework (AONE, 2016). The system’s nurse executive sent a letter to all participants informing them of the organization-endorsed program, which they had been recommended to attend. The letter also informed the FLNLs that they could decline to attend. The participants were given overview information in writing on the first day, which included expectations, framework, class schedules, and quality project requirements.
The curriculum (based on the NMLP and Nurse Manager competencies as identified by AONE and AACN) was designed to assist in developing tools needed to advance experience, knowledge, confidence, education, and the continued ability to contribute to high-quality, evidence-based practice necessary to lead effectively. Each class was divided into three focused elements. Two hours of lecture and discussion components focused on the identified competencies and were led by subject matter experts from the facility or university. One hour concentrated on building the leader within and was led by an experienced Chief Nursing Officer and professor, focused on the art of reflection and leadership development. The last hour centered on peer socialization and development through small work groups and/or open discussions.
The sample for this project included 38 FLNLs, 20 in the first cohort and 18 in the second cohort, at a large urban hospital facility. FLNLs attending the program were required to be currently employed at the facility and in good standing. Following the completion of this study’s analyses, post hoc power analyses were conducted in order to determine the actual levels of power associated with the results obtained. Overall, these results indicate an acceptable level of statistical power.
Each attendee was given time away from work to attend classes. There was no cost to the participants; the FLNLs were paid their normal salary, and class time was coded as education. The risks and benefits of attending the program were heavily weighted toward benefits. The participants were asked to attend all classes, complete a quality improvement project presented during a graduation ceremony, and complete the pre- and postsurveys.
INSTRUMENTATION AND ANALYSIS
The data were gathered using the demographic tool and NMIT. Demographic data were used to match person-to-person results in assessing pre- and postcompetency levels and further analysis. The NMIT, which captures the skills and behaviors that are envisioned for the successful FLNL, was used to self-score competency levels with the assumption that the scoring was completed honestly. The inventory is based on a model of three overlapping and interconnected domains in which the successful nurse managers should gain expertise and competency. FLNLs should be trained in the skills set and competencies needed not only to fulfill their daily responsibilities but also to lead the change needed in the demanding healthcare field. Reliability and validity for the nurse manager competencies is established by periodic job analysis/role delineation through a national practice analysis study of the nurse manager and leader (AONE, 2016). Cronbach’s alpha coefficient varied between 0.88 and 0.96, and validity was confirmed with a three-factor solution that explained more than 60% of the variance.
Initially, a series of descriptive statistics were conducted on the measures of years of experience as a nurse, years of experience as an FLNL, and highest level of education attained to provide an initial illustration of these data and the respondents within this project (see Table 1).
Pre- and postproject surveys provided measurable data used to evaluate improvement in leadership skills. Data from the surveys were analyzed using SPSS 26 for descriptive statistics and paired t tests with Holm’s corrections. The results of descriptive statistics indicated improvement in each individual’s overall competency as well as the 15 nursing leadership competencies investigated within this project. Prior to this project, working as an FLNL and receiving on-the-job training did not lead to proficient or expert leaders. Even the FLNLs who had worked greater than 6 years in their position were hovering at the lower end of the competent ranking. Only after attending the curriculum did the FLNLs with years of experience begin to approach the proficient to expert competency levels of the NMIT competencies as indicated by the results of paired t tests with Holm’s corrections (see Table 2). Individual self-competency rankings improved by 25.8%, with overall rankings of everyone’s overall competency. These results indicated the efficacy of the program. In addition, within the analysis conducted on competency rankings based on nursing experience, FLNL experience and education levels indicated a consistency between cohorts, education levels, and different nursing experiences.
Implications for this project span theoretical, practical, and future practice improvements. The primary focus of this project centered on improvement of competencies of the FLNL, which in turn improves outcomes. FLNLs who have received on-the-job training are not typically introduced to important topics such as strategic management, relationship management, influencing behaviors, shared decision-making, reflective practice, or foundational thinking skills, which are transformational in nature.
Developing a culture where nurses are engaged in evidence-based practice requires transformational leaders. FLNLs that focus only on transactional activities (i.e., staffing, crisis management, etc.) do not employ transformational skills. They are just getting by (Manning, 2016) and focus only on completing tasks, which does not lead to an engaged patient environment. If FLNLs are to develop the needed culture where patient engagement is the norm, they should be given tools to move past transactional tasks and practice only in laissez-faire or transactional leadership realm of the FRLT. Transformational leadership is developed overtime in FLNLs who have a grounded framework in practicing reflection, FRLT, and evidence-based practice.
Demonstrating that all 38 FLNLs improved in these foundational competencies after attending the FLNL curriculum reinforces the need for formal professional development of FLNLs. Peer socialization and evidence-based practice are outcomes of attending the program where FLNLs collaborated among other FLNLs in class, during peer socialization, and on projects, where they shared evidence-based practices occurring on their units as well as implementation of their evidence-based practice project. With the continual changes that occur in health care, FLNLs are expected to maintain healthy work environments, where staff choose to stay and are engaged in professional practice of patient-centered care and engagement. The FLNLs who only received on-the-job training tend to rely on laissez-faire and transactional leadership styles and need to cultivate leadership competencies that cannot be learned by performing merely transactional management.
New FLNLs should undergo a baseline competency assessment such as the NMIT; this will assist them to develop a framework in building competencies as a leader. They should be introduced to leadership skills formally in a curriculum in which peer socialization and educational resources are directed toward improving leadership competency. This will ensure they begin their leadership transition grounded in evidence-based science (Caramanica, 2010). Nurse managers who are given only on-the-job training and left to develop their own framework of leadership are more likely to develop work-around cultures, which is not a culture where patient-centered care is delivered or which focuses on patient engagement and a culture of safety (Lefton, 2010).
Recommendations from this project are far reaching for FLNLs, nursing staff, and patients. FLNLs set the tone for the culture on their units, and with professional development based on the NMLP, they are better equipped to implement evidence-based processes and standards, which improves outcomes for both patients and staff. FLNLs left to develop competencies on their own are likely to find workarounds (Lefton, 2010), but those who have participated in formal development programs are more likely to implement an evidence-based practice culture (Caramanica, 2010).
FLNLs oriented with only on-the-job training are limited to primarily transactional activity training. However, Foon (2016) identified that nurse leaders should be competent in both transactional and transformational styles of leadership to be successful in different situations and while working with subordinates of varying abilities, which contributes to nurse job satisfaction and retention. Ensuring that nursing teams are functioning at the highest levels require that FLNLs have the tools for not only their own development but which also enhances teamwork, promoting patient safety and nurse satisfaction (Clark, 2009).
The relationship between what managers do and optimal outcomes are well established (Cummings, 2011). Collectively, the work of Hofmeyer (2013) and Avolio, Gardner, Walumbwa, Luthans, and May (2004) show that cohesive teams have a positive impact on patient outcomes. Successful FLNLs who are competent in relationship building are better prepared to develop strong cohesive teams who deliver high-quality care.
This project, which was limited due to time constraints, falls short of showing improvement in patient outcomes and nursing satisfaction, although the nursing literature supports improvement in FLNL’s competency will improve both. Future projects to consider:
- Conducting a leadership development program for FLNLs and analyzing trending competency scores and patient satisfaction scores. This project could be conducted with comparison of pre- and postcompetency scores of nurse managers before and after attending a leadership development program in comparison to patient satisfaction scores measured at the same time intervals. With monitoring of patient satisfaction scores, the impact of nurse manager competency improvement could be analyzed over time. In this data comparison, improvement in patient satisfaction scores would reinforce literature findings of improved FLNL competency impact on outcomes and validate the primary investigator’s conceptual model (see Figure 1).
- Comparison of competency assessments between a control group who receive formal leadership development and an on-the-job trained group. Competency assessments could identify if leadership program attendance versus time and experience on the job improves FLNL competency, which has been shown to impact patient satisfaction, engagement, and outcomes and will validate the primary investigator’s project conceptual model as shown in Figure 1.
- Analyzing pre- and postnursing satisfaction results for the units where FLNLs had attended a leadership development program. This would validate impact on nursing work environment, satisfaction, and engagement when the FLNL participates in formal leadership development. In this project improvement in nursing, satisfaction scores would reinforce literature findings of improved FLNL competency impact on these outcomes and validate the primary investigator’s project conceptual model as shown in Figure 1.
- A longitudinal project could be conducted with a metadata comparison of patient satisfaction, nurse-sensitive indicators, and nursing satisfaction and engagement, pre- and postprogram, at 1- and 2-year intervals trending outcomes and satisfaction on units where FLNLs had participated in the leadership development program. This would validate the impact on nursing work environments, satisfaction, and engagement when the FLNL participates in formal leadership development.
These research projects considering improvement in nursing satisfaction scores, reduction in nurse-sensitive indicators, and improvement in patient satisfaction and outcomes would reinforce literature findings of FLNL’s competency impact on these outcomes and validate the primary investigator’s project conceptual model as shown in Figure 1.
To ensure that FLNLs are developing competencies as identified by NMLP, they should attend a formal development curriculum that includes a program project. Training FLNLs in the art of reflections is an important element of the leadership development curriculum and improves team effectiveness, which has a direct correlation with nurse satisfaction and the quality of care delivered (Govier & Nash, 2009). Becoming a successful FLNL involves acquiring skills to lead and motivate a team while ensuring that standards of care remain high. This program focused on assisting FLNLs in acquiring the necessary skills needed to perform their jobs while providing mutual support for these leaders.
The outcome of this project illustrated that FLNLs who attended the leader training program were more confident as they transition to expert leaders while learning to lead effective teams succinctly. Developing and implementing training for FLNLs will ensure that expert clinicians’ transition to expert FLNLs who can develop strong healthcare teams in which safe patient environments and high quality of care are not only buzz words but actualized byproducts of the daily culture.
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