Healthcare systems are facing tumultuous, challenging times that are likely to become the new normal. As crucial members of the healthcare team, the nurse leaders of today are faced with ever-increasing responsibilities; higher levels of accountability; and multiple, ongoing stressors that can have a detrimental impact on a nurse leader's ability to succeed. In response to these challenges, it is important to understand, develop, and adapt skills required for nurses to thrive and succeed as transformational leaders. However, the factors that contribute to the nurse leader's ability to persevere and maintain a sense of well-being through unprecedented times are not fully understood. This study focuses on a personality quality termed grit, defined as a perseverance of effort and consistency of interest and the ability to thrive in the face of perpetual challenges and continual change. The goal of the study is to explore the association between the personality trait of grit and the well-being of nurses who serve in positions of healthcare leadership.
Well-being of Nurse Leaders
Successful leaders hold themselves accountable to their values and their commitments.1 As the responsibilities of nurse leaders become increasingly complex, it is becoming progressively more difficult for today's nurse leader to experience job satisfaction and fulfillment. All levels of nurse leadership may be adversely affected throughout the full range of healthcare settings. Evidence for burnout and fatigue among nurses is documented throughout the literature2,3 and is apparent in the high organizational costs associated with recruiting, hiring, and training nurses to replace those lost to attrition.4 One literature citation estimates nurse turnover costs ranging from $500 000 to more than $8 million since 1990.4 Actual costs for nurse leader turnover are unknown, but the American Organization of Nurse Executives (AONE) reports vacancy rates for nurse managers are on average as high as 8.3% nationwide.5 As healthcare and technology spiral into a state of constant change, the need for strong, committed effective leadership is essential. Thus, the requirement for nurse leaders to succeed is a crucial one.
Is Grit a Predictor of Success for Nurse Leaders?
Grit is a noncognitive variable that has received substantial attention outside the nursing profession as an important predictor of success and performance. Grit, a personality trait, is defined as “perseverance and passion for long-term goals” and as “… not just resilience in the face of failure, but also having deep commitments that you remain loyal to over many years.”6(p1087) Duckworth and colleagues6,7 demonstrate that between-person differences in grit can help to explain why 2 individuals with the same level of ability in a particular field are often observed to perform at substantially different levels. Specifically, individuals with high levels of grit are thought to be able to better utilize their capabilities because they are less distracted by short-term goals and less discouraged by the failures and setbacks that are commonly encountered in many performance domains.8 In studies focused on drivers of success, the importance of grit is also in line with work that has highlighted the importance of sustained deliberate practice9,10 and conscientiousness.6,11,12 Additionally, perseverance coupled with a sense of competence and excellence correlates with fewer absences, decreased risk of turnover and increased ability to handle the demands of the job.13,14 Whether or not grit as defined by Duckworth et al6 represents a core personality trait among successful nurse leaders is the focus of this study. The study explores the association between grit and achievement in nurse leaders. Specifically, using previously validated personality questionnaires, this researcher examines the association between Grit scores among nurse leaders and longevity in leadership roles, a commitment to lifelong learning, and measures of personal accomplishment. A 2nd goal of this work is to assess whether nurse leaders with high scores on grit experience less burnout. This work contributes to the limited prior research on the association between leadership and grit in healthcare. Moreover, this study provides the 1st empirical findings on the association of grit with the well-being of nurse leaders.
The study was approved by the Northeastern University institutional review board. Study participants were members of the AONE and other nurse leaders who responded to the survey link. AONE members were asked to invite their colleagues by forwarding the AONE newsletter and survey link. The request to participate was sent to approximately 9000 AONE members who subscribe to mass email communication.
Recruitment and Consent
A request to participate was deployed through the AONE weekly e-newsletter titled AONE Working for You. A web-based consent was obtained from each participant. All data were deidentified and kept confidential.
Selection of Individuals to Participate in the Study
The following inclusion criteria were used to select a purposive sample of nurse leaders from among those who responded to the recruitment request: nurses who self-identified as leaders, who are AONE members or their colleagues (according to the AONE media flier approximately 95% of the members have a manager level of responsibility or above), who are literate in English, and who have basic computer skills. The focus was on nurse leaders based on the assumption that their success and well-being would have a greater impact at all levels of healthcare.3 AONE members who opted out of mass email communications and nurses who did not self-identify as a leader for 1 year or greater were excluded. The recruitment time period was over 4 months in 2017.
The study used validated tools to measure grit, burnout, and professional achievement. The Short Grit Scale (Grit-S) instrument consists of 5 Likert-scale answer choices to a series of 8 statements.15 The Grit-S retains the 2-factor structure of the original Grit Scale with 4 fewer items and improved psychometric properties.6 The Maslach Burnout Inventory–Human Services Survey (MBI-HSS) instrument consists of 6 answer choices to a series of 22 statements.16 The MBI-HSS instrument includes 3 subscales: personal accomplishment (PA), emotional exhaustion (EE), and depersonalization (DP). The Grit-S and the MBI-HSS questions were interleaved, and additional demographic questions were added to create a single questionnaire that was sent via email from the investigator to the individuals selected for participation in the study. Repeat e-newsletter emails with the survey link were sent weekly. Participants had 8 weeks to complete the survey. Permission to use the AONE e-newsletter, the Grit-S, and the MBI-HSS was explicitly requested and granted. All requirements of these permissions were adhered to throughout the project.
Data Collection and Analysis
Study data were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools (Vanderbilt University, Nashville, Tennessee) hosted at Massachusetts General Hospital. REDCap is a secure, web-based application designed to support data capture for research studies, providing 1) an intuitive interface for validated data entry, 2) audit trails for tracking data manipulation and export procedures, 3) automated export procedures for seamless data downloads to common statistical packages, and 4) procedures for importing data from external sources. Each participant provided a self-assessment response to multiple statements within each of the 4 personality scales (Grit, PA, EE, and DP). For each individual, the multiple responses to statements within the Grit-S were averaged to create a single numeric Grit score for that individual. The same was then done for each of the multiple responses within the PA, EE, and DP scales. Thus, each participant contributed 1 score for each of the 4 scales. The sign was reversed as appropriate for the wording of each item. Because the scale for PA is positive and the scales for EE and DP are negative, a composite score for burnout was determined by using the value (6.0 − PA) to combine the PA with the other subscales. MBI data were analyzed using this composite score as well as each of the subscales. Grit-S was not broken down into further subscales consistent with Duckworth's methodology. For both MBI and Grit-S, all items were included in the analyses below. Data were analyzed using SAS version 11 (Cary, North Carolina).
Five hundred nineteen surveys were returned. The distribution of respondents throughout the United States is shown in Supplemental Digital Content 1, http://links.lww.com/JONA/A677. Of the 519 participants, 410 individuals completed the survey questions and form the basis of the analysis. Demographics of the participants are shown in Table 1. Most participants were female (n = 367 [92.4%]). The average age was 49 years, ranging from 24 to 76 years (SD, 12.13 years). The average duration of nurse leadership experience was 8.27 years, ranging from 0.25 to 50 years (SD, 8.62). Most participants had a master's degree in nursing or higher (n = 368 [93.8%]).
Among the 410 participants, 392 individuals provided information on years in current leadership role. Table 2A shows the mean (SD) of scores for grit, overall MBI, and the 3 subscales of MBI (PA, EE, DP) according to different levels of leadership experience. The Grit score ranges from 0 to 5 and is designed to have an average score of 2.5 in an unselected population. The MBI score ranges from 0 to 6 and is designed to have an average score of 3 in an unselected population. As shown in Table 2A, the nursing participants reported an overall average Grit score of 3.98 ± 0.45 and an overall MBI score of 4.62 ± 0.78. The average Grit score of participants progressively increased with increasing years of leadership experience from 3.94 ± 0.45 among 272 individuals with 1 to 10 years of experience to 4.11 ± 0.44 among 42 nurses with 20+ years. The association of increasing Grit score and increasing experience was statistically significant, P < .03 (analysis of variance [ANOVA]). In a similar way, the average MBI score of participants progressively increased with increasing years of leadership experience from 4.52 ± 0.77 among 272 individuals with 1 to 10 years of experience to 4.89 ± 0.75 among 42 nurses with 20+ years. The association of increasing MBI score and increasing experience was also statistically significant, P < .001 (ANOVA). Within the subscales of MBI, nurses with greater experience also had significantly lower burnout scores (EE scale) and lower depersonalization scores (DP scale). A similar analysis for variation in personality scores according to education level is shown in Table 2B. Of interest, Grit score and overall MBI score did not differ significantly among those with and without advance degrees (Grit, P = .14; MBI, P = .14). Notably, there were only 29 respondents in the lower category of education defined as bachelor's degree or below.
To further understand the relationship between Grit and MBI scores, the association between Grit score and each of the 3 MBI subscales was examined. Figure 1 shows the scatter plots of Grit score versus each of the 3 subscales of MBI. Scatter plot was used to graphically display the relationship between 2 measures; Pearson correlation coefficient was used to estimate the strength of the relationship. In general, there is a positive association between Grit and PA scores. As Grit score increases, PA score also increases (r = 0.38, P < .001). However, the associations between Grit and EE and DP scores were slightly weaker (r = −0.35, P < .001). We further combined PA, EE, and DP scores to create an average composite MBI measure for each individual as a summary score for burnout. Because the PA scale is reported in the opposite direction of the DP and EE scales, we used the difference between each subject's PA score and the maximal score of 6.0 when calculating the composite score. Cronbach's α suggested a high internal consistency (0.70) of combining 3 scales into 1 measure. As seen in Figure 1D, a statistically significant and negative correlation was found between Grit and composite MBI (burnout) (r = 0.45).
Despite the challenges of modern healthcare, there has been very little research to investigate the personality qualities that are associated with longevity in the nursing profession and a sense of personal accomplishment among nurse leaders in the United States. This study was undertaken to explore the hypothesis that a personality feature termed grit is associated with career satisfaction. By identifying participants from the membership of the AONE, personality traits were analyzed from more than 400 nurse leaders across the United States.
The results show that Grit scores among nurse leaders increase with greater career longevity in leadership roles and that high Grit scores are associated with an increased sense of personal accomplishment and reduced feelings of burnout. The data also suggest that nurse leaders with higher Grit scores are lifelong learners and pursue advanced degrees throughout their careers.
We found a significant association between higher Grit scores and years of experience. While this could indicate that development of the personality trait led to long-term success, it is equally possible that the association was not due to learning grit but rather due to dropout of individuals who scored lower on the scale for this personality feature. Thus, our findings do not indicate conclusively that training for grit would lead to higher levels of nursing success.
Moreover, the correlation coefficient between Grit and MBI indicates that this personality trait does not account for all the variation in MBI. Undoubtedly, other aspects of the individual—such as creativity, ability to innovate, and experience—and aspects of the work environment—such as team support, fairness, and common goals—contribute to overall nursing success.
Nevertheless, research-grounded insights have shown that building grit is possible. Grit curricula focus on practical strategies that help one become a grittier person. Some strategies include identifying role models, seeing 1 or 2 goals across the finish line, cultivating a growth mindset, and finding purpose in work. Thus, to teach grit effectively, one needs to help nurse leaders cultivate grit in the context of their unique personality traits and environment.
Although the findings of this study suggest that measuring grit may be 1 way to identify future nurse leaders or predict which current nurse leaders will stay the course, there may be limitations. A strong grit personality trait is by no means the only measure of leadership success. Although grit may be an excellent predictor of an individual's ability to complete military basic training or succeed in well-defined academic tasks, it may be counterproductive for performance on tasks that are very easy (thus not requiring grit) or performance on tasks that are novel and ill-defined and that therefore require both creativity and the willingness to abandon unsuccessful strategies. Furthermore, very high levels of grit may become dysfunctional if they reduce the likelihood of help-seeking behaviors that have themselves been linked to performance17 or if they increase the likelihood that an individual persists too long in attempting to solve a problem that is particularly difficult rather than spending time on other, more solvable problems.18 Although grit has been shown to be an important aspect of long-term success in other professions, analysis of grit is in the early stages of development for nursing leadership and requires further examination.
Identification of nurse leaders is necessary for the future sustainability of healthcare. Nurse leaders are the individuals who inspire and uphold those who provide the most intimate and pivotal care for patients and families in every healthcare setting.19 Reducing burnout and ensuring success and longevity for nurse leaders have been 2 of the core focuses for hospitals.20 If grit really works as both a diagnostic tool and a target for intervention, it may serve as a motivational tool of self-awareness and may also identify individuals who might otherwise be passed over for career advancement. For example, grit assessment could have a role in drawing nursing leadership from a more diverse talent pool. Thus, organizations might be able to use grit as a measure to identify nurse leaders who could benefit from additional support and coaching to prevent burnout and attrition as well as identify those who are more likely to engage in long-term success.
Furthermore, grit may be related to why some nurse leaders choose to leave their position rather than persevere. Given the costs associated with attrition of nurse leadership in this country,4 it is important to understand the factors that influence nurses to leave their profession. Although the exact percentage is unknown, there is a trend among younger nurse leaders to leave positions within the 1st 1 to 2 years of accepting the role.21 This attrition is costly for both the individuals affected and their organizations.21 For example, the cost of replacement for a perioperative director can run $132 000 to $228 000 or more if the process takes longer. Although there are many factors that are likely to contribute to attrition, including adverse lifestyle effects of long nursing hours and difficult work environments,20 grit may be a measurable identifier of a force preventing workplace attrition.
Although assessment of grit might be a useful measure for healthcare organizations to incorporate into their screening process for nurse leaders, there are some limitations and constraints to consider. For example, grit scores may be confounded by age. In a study aimed at working professionals with a bachelor's degree or higher, Duckworth et al6 found that grit was lowest among 25- to 34-year-olds and highest among those 65 years or older. Similarly, this study noted a statistically significant association of Grit score with years of service as a nurse leader. Thus, direct comparison of Grit scores might put younger, emerging nurse leaders at a disadvantage unless an age-adjusted evaluation was considered. Because the scoring is based on self-assessment, which varies according to mood and emotion, it might be more useful to average scores across grit surveys done at different time points.
There are several important limitations of this study. First, it is difficult to define the population of nurse leaders in the United States; thus, although survey responses were well distributed across the country, generalizability may be limited, and selection bias may have occurred. Furthermore, this study is qualitative and identifies important associations but does not indicate causal relationships of any kind. Because information about each individual's duration of leadership experience was collected at a single point in time, it is impossible to capture the outcome of greatest interest, attrition. Additional experimental and longitudinal research may provide causal evidence for the relationships emerging from this study.
Implications for Future Study
To provide a deeper understanding of grit as it relates to nurse leaders, future studies should include the assessment of nurse leader's perspectives using interviews to capture defining moments and scenarios of grittiness. Capturing this information is a 1st step in refining the grit assessment tool to match the context of the nursing professional. This more refined assessment may also include capturing information on the act and practice of grittiness and its impact on workplace culture. This researcher hopes that greater rigor in grit scale development and a more nuanced approach in study design will help future grit researchers to develop boundary conditions for grit in its role as an influence on performance and success in nursing.
In conclusion, this study shows a significant association between the personality trait defined as grit and career longevity, higher educational attainment, and lower scores for burnout among a large group of nurse leaders surveyed from throughout the nation. The findings may be relevant for efforts designed to address current and future challenges facing nursing in healthcare organizations.
1. Ailey S, Lamb K, Friese T, Christopher BA. Educating nursing students in clinical leadership. J Nurs Manag
3. Cline S. Nurse leader resilience. Nurs Adm Q
4. Li Y, Jones C. A literature review of nursing turnover costs. J Nurs Manag
5. AONE leadership perspectives. Acute care hospital survey of RN vacancy and turnover rates in 2000. J Nurs Adm
6. Duckworth AL, Peterson C, Matthews MD, Kelly DR. Grit: perseverance and passion for long-term goals. J Pers Soc Psychol
7. Duckworth A. Grit: The Power of Passion and Perseverance
. New York, NY: Scribner; 2016.
8. Credé M, Tynan MC, Harms PD. Much ado about grit: a meta-analytic synthesis of the grit literature. J Pers Soc Psychol
9. Ericsson K, Krampe R, Tesch-Roemer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev
10. Krampe R, Ericcson K. Maintaining excellence: deliberate practice and elite performance in young and older pianists. J Exp Psychol
11. Duckworth A, Kirby T, Tsukayama E, Berstein H, Ericsson K. Deliberate practice spells success: why grittier competitors triumph at the National Spelling Bee. Soc Psychol Pers Sci
12. Perkins-Gough D. The significance of grit: a conversation with Angela Lee Duckworth. Educ Leadersh
13. Shanafelt T, Boone S, Oreskovich M, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med
14. Giles S. The most important leadership competencies, according to leaders around the world. Harv Bus Rev
15. Duckworth A, Quinn P. Development and validation of the Short Grit Scale (Grit-S). J Pers Assess
16. Maslach C, Jackson S, Leiter M, Schaufeli W, Schwab R. Maslach Burnout Inventory Instruments and Scoring Guides Forms: general, human services & educators. Health Qual Life Outcomes
17. Karabenick S. Seeking help in large college classes: a person-centered approach. Contemp Educ Psychol
18. Lucas G, Gratch J, Cheng L, Marcella S. When the going gets tough: grit predicts costly perseverance. J Res Pers
19. Stagman-Tyrer D. Resiliency and the nurse leader: the importance of equanimity, optimism, and perseverance. Nurs Manage
20. Udod S, Cummings G, Care W, Jenkins M. Impact of role stressors on the health of nurse managers: a western Canadian context. J Nurs Adm
21. Sherman R, Patterson P, Avitable T, Dahle J. Perioperative nurse leader perspectives on succession planning: a call to action. Nurs Econ
Supplemental Digital Content
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.