The Relationship of Training and Education to Leadership Practices in Frontline Nurse Leaders

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1 JONA Volume 44, Number 3, pp Copyright B 2014 Wolters Kluwer Health Lippincott Williams & Wilkins THE JOURNAL OF NURSING ADMINISTRATION The Relationship of Training and Education to Leadership Practices in Frontline Nurse Leaders Lesly A. Kelly, PhD, RN Teri L. Wicker, PhD, RN Richard D. Gerkin, MD, MS BACKGROUND: Although organizations strive to develop transformational leaders, frontline nurse managers and directors are often inadequately prepared and lack transformational leadership (TL) behaviors. OBJECTIVE: To examine the relationship of TL practices, nurse characteristics, and formal leadership training of frontline nurse leaders in a large health system. METHODS: A survey of 512 frontline nurse leaders in 23 hospitals assessed demographic characteristics, the amount of leadership training received, and selfperceived leadership behaviors, measured through the Leadership Practices Inventory. RESULTS: Formal training influences only 1 component of TL behaviors, helping train leaders to model the way for their employees. Increasing a nurse leader s level of formal education has a significant effect in improving overall TL practices and behaviors that inspire a shared vision and challenge the process. CONCLUSION: To build transformational frontline nurse leaders, organizations should balance formal Author Affiliations: RN Clinical Research Program Director, Banner Good Samaritan Medical Center, and Assistant Research Professor (Dr Kelly), Arizona State University, Phoenix; Medical Director of Graduate Medical Education, Research Banner Good Samaritan Medical Center, and Associate Professor of Clinical Medicine (Dr Gerkin), Department of Internal Medicine, University of Arizona College of Medicine, Phoenix; Professional Practice Director (Dr Wicker), Banner Heart Hospital, Mesa, Arizona. This research was funded by a grant from the American Organization of Nurse Executives Research Foundation. The authors declare no conflicts of interest. Correspondence: Dr Kelly, Banner Good Samaritan Medical Center, 1111 E McDowell Rd, Phoenix, AZ bannerhealth.com). DOI: /NNA leadership training programs with advanced degree attainment to encourage leaders to envision and challenge the future. With a solid body of evidence related to effectiveness, nurse leaders are expected to utilize transformational leadership (TL) practices. 1-4 However, the reality is that nurse leaders are often promoted into positions unprepared to lead others and struggle to develop their leadership skills. Hospitals and health systems have created leadership training programs to develop nurse leaders, focusing on training nurse leaders to develop their TL practices. 5,6 The purpose of this article was to describe a large descriptive study examining the relationship between nurse characteristics, formal leadership training, and TL practices. Background Nearly 3 decades of research has produced a body of evidence describing TL style as it relates to leading others. 4,7,8 Originally developed by Burns, 9 and then described in leadership models through Bass and Avolio 6,10,11 and Kouzes and Posner, 12 TL is characterized as leading through motivating others. Rather than rewarding employees for tasks or operational practices, which is a transactional style of leadership, TL encourages employees to envision and achieve change. 6,11 Organizations with transformational leaders create a synergistic environment for leaders to manage change creatively, 13 using intrinsic motivation to move individuals and groups to exceed expectations. This is often accomplished by having a clear vision and effectively communicating it to all employees in a consistent manner. 7,12, JONA Vol. 44, No. 3 March 2014

2 As a result, nurses respond well to TL style practices because it builds and develops relationships that lead to empowerment, which in turn allows the accomplishment of goals. 6,15 Evidence supports the theory that effective nurse leaders are capable of transforming environments with open communication, nurse empowerment, autonomy, and shared responsibility in decision making. 1,8,16,17 Accordingly, TL has been associated with enhancing nurse satisfaction and nurse empowerment, resulting in improved recruitment and retention, and potentially improving patient outcomes. 2,18,19 Transformational leadership style has been operationalized through the development of Kouzes and Posner s 15 5 structure model of exemplary leadership practices and measured through the corresponding Leadership Practices Inventory (LPI) survey tool. The 5 practices of exemplary leadership include (1) modeling the way, (2) inspiring a shared vision, (3) challenging the process, (4) enabling others to act, and (5) encouraging the heart. 15 Each concept describes specific practices a leader engages in to motivate his/her employees using a TL style. 12 Research demonstrates that nurse leaders who institute these practices have strong communication, meet organizational values, and have a high level of impact. 3,19,20 Despite the body of evidence favoring TL style, nurse leaders are often not adequately prepared to act as transformational leaders. Frontline nurse leaders, identified as nurse leaders directly responsible for staff that provides patient care, are often promoted into these positions because they have excelled in their clinical positions. Sometimes, these positions require a bachelor s or master s degree, but often there is no additional training or direct leadership education. In addition, nursing leadership has been plagued with problems such as no formal job description, an increase in responsibility without an increase in authority, and a lack of leadership education. 21 In general, nurses are promoted into frontline leadership positions without formal training and education to manage day-to-day operations, including human resource management. Rather than experiencing formal training or mentorship, nurse leaders informally learn from each other and adopt leadership practices based on situational circumstances, which can potentially lead to conflict that can be correlated to leadership styles and practices. 5,22,23 Opportunity for Research A large health system in the Western United States developed a leadership academy to train individuals in leadership skills and competencies. The academy consisted of a formal organizational leadership development program with didactic workshops related to building leadership behaviors, including on-boarding activities, communication and financial skill development, leadership style, motivation, and employee performance. All leaders, including nursing and nonnursing departments, were informally assigned to attend the development program upon assuming their leadership position. The academy includes a new leader orientation and approximately 9 workshops deemed appropriate to building skills for their leadership development. The health system uses 3 levels of frontline nursing leadership, in the acute care facilities. Clinical managers (CM) have the most direct interaction with the staff and patients and could be similarly compared in other organizations to charge nurses, team leaders, or shift managers. Senior clinical managers (SCM), the next level of leadership, have increased operations, budget, and staffing responsibilities. Directors, the highest level of frontline nursing leadership, report directly to the chief nursing officer. They are responsible for service lines, which may include multiple units, and have complete oversight and operational responsibility for the department. Because of the training opportunities and standardized frontline nurse leader roles within a large health system, a research study was developed to ask the question, Does formal training increase TL practices? The aims of study were to (1) describe a large sample of frontline nurse leaders, including demographics, amount of leadership training received, and leadership behaviors; and (2) analyze the relationship between frontline nurse leader s demographics, amount of leadership training received, and leadership behaviors. Methods Design, Setting, and Sample The study was a multisite cross-sectional descriptive survey of frontline nurse leaders in a single health system consisting of 23 urban and rural hospitals in 6 states. To be included in the study, the nurse must have been employed in an acute care facility in the healthcare system and have held a frontline nurse leader position, defined as a CM, SCM, or director. Chief nursing officers were excluded because of the small number of respondents. Nurse leaders in clinical support roles (eg, clinical nurse specialists, case managers, educators) and nonnursing positions (eg, the director of finance is a nurse but in a nonnursing position) were excluded. The study was approved by the organization s institutional review board for human subject s protection. JONA Vol. 44, No. 3 March

3 Data Collection and Instrument A pen-and-paper survey was given to participants during their monthly nurse leadership meeting. The study was introduced by the investigators, and participants received the survey and an envelope. The participants completed the survey, sealed it in the envelope, and returned it to investigators at the end of the meeting. Participation was voluntary, and participants could choose not to take a survey or could seal a blank survey in the envelope. The survey consisted of 3 parts: (1) demographics, (2) questions related to the amount of leadership training the nurse leader had received, and (3) the LPI. 12 Demographics collected included leadership title, age, number of years as a nurse, number of years as a frontline leader, highest educational degree attained, certification, and span of control. Leadership training was defined for the participant as time spent enhancing skills or behaviors to improve their ability to perform in their position. Nurses were asked to identify which of the organization s leadership academy courses they had completed and describe any additional leadership training they have received, such as a webinar, leadership conference, or online training. In addition, an option to enter free text to describe additional leadership training opportunities was included. The 3rd part of the survey was the highly validated LPI, 12 a 30-item questionnaire to measure self-perceived leadership practices. The LPI has been widely used in nursing and other industries (internal consistency ratings ranging between 0.78 and 0.93). 3,12 The instrument asks the participant to rate how frequently they engage in leadership behaviors that align with TL style. Permission to use the LPI was obtained from the authors. Data Analysis Survey responses were transcribed into Microsoft Excel An audit of 10% of the surveys was conducted to verify accuracy of data transcription. After all surveys were entered and data were validated, the workbook was imported into Statistical Packages for the Social Sciences (Chicago, Illinois) 24 for analysis. Descriptive statistics were used to analyze demographics and amount of leadership training, including means, percentages, and SDs. The LPI was analyzed 2 ways: as a total score and through its validated 5-subscale structure. The total LPI was calculated as the sum of a participant s responses to the LPI. Subscale scores were calculated as means for the 6 questions identified for each subscale. All descriptive statistics were reported by level of leadership title (CM, SCM, and director) for comparison purposes. To analyze the relationship between demographics, leadership training, and TL practices, stepwise regression modeling was used to assess the predictability of leadership training on higher LPI scores, controlling for demographics. In other words, statistical modeling was used to determine if training or other demographic variables were a significant independent predictor of higher leadership practices (higher LPI scores). A 2-tailed P G.05 was considered significant. Results Surveys were collected from frontline nurse leaders (response rate 51%, n = 512) from all 23 hospitals, including CMs (45%, n = 281), SCMs (59%, n = 141), and directors (60%, n = 90). Demographic characteristics, amount of leadership training, and LPI total and subscale scores are reported in Table 1 by level of Table 1. Demographic Characteristics of Nurse Leaders CMs (n = 281) SCMs (n = 141) Directors (n = 90) P a Years of experience (10.19) (9.42) (10.50) G.001 Age (10.15) (8.65) (9.59).001 Years as frontline leader 6.13 (6.17) 7.42 (6.23) (8.10) G.001 Leadership tenure at health system 4.37 (4.80) 5.88 (5.54) 7.52 (6.90) G.001 Certified, % Education, % G.001 Diploma Associate degree Bachelor s degree Master s degree or higher Span of control (21.28) (44.12) (78.08) G.001 Attended new leader orientation, % Average no. of leadership academy courses 3.96 (2.60) 6.10 (2.77) 6.99 (2.27) G.001 Average no. of optional training courses 0.36 (0.62) 1.10 (1.12) 1.88 (1.30) G.001 Average total training (academy + optional) 4.32 (2.83) 7.20 (3.19) 8.89 (2.85) G.001 Reported as mean (SD) unless otherwise indicated. a Analysis of variance used to test for differences between means of continuous variables and 2 2 used to test for differences between categorical variables. 160 JONA Vol. 44, No. 3 March 2014

4 Table 2. Summary of Leadership Practices CMs (n = 281) SCMs (n = 141) Directors (n = 90) P a LPI Normative Database LPI total (27.67) (26.33) (27.78) G.001 V Challenge (7.32) (6.93) (5.77) G Inspire (8.03) (7.28) (6.17) G Model (5.51) (5.46) (4.45) Enable (4.57) (4.30) (3.98) Encourage (6.47) (6.65) (5.94) Reported as mean (SD) unless otherwise indicated. a Analysis of variance used to test for differences between means of continuous variables; LPI total ranging from 0 to 300; subscales range from 0 to 60. leadership title. Of note, the average demographic and amount of leadership training increased with each level of leadership title. Table 2 presents a summary of the total LPI score and the average score of each of the 5 subscales for the nurse leaders by level of leadership. Significant differences were seen between each level of leadership, except for the encourage the heart subscale, where scores were similar at each level of leadership. All levels of leadership scored the highest on the enable others to act subscale. The last column of Table 2 indicates averages from the LPI normative database, a collection of more than 1.1 million responses from the LPI tool published by the authors. 25 All levels of nurse leaders in the study scored higher than the LPI normative average subscale score. Reliability for the LPI was assessed for the overall scale (" =.95). To examine the relationship between demographics, training, and leadership behaviors and determine significant predictors of leadership behaviors, stepwise regression analysis was conducted on the total LPI score and each of the 5 subscale scores. Table 3 indicates title, training, and education were significant predictors of leadership practices. Title significantly predicted the overall LPI total score and 3 of 5 of the subscales: challenge the process, inspire a shared vision, and enable others to act. Training significantly predicted increased scores on only the model the way subscale. Education was a significant predictor of the total LPI score and both challenge the process and inspire a shared vision subscales, while holding title constant. No significant predictors were found for increasing leadership behaviors in the encourage the heart subscale. Discussion It is critical for frontline nurse leaders to develop TL behaviors in order to be successful in their roles. 2,5 This study provides a description of more than 500 frontline nurse leaders in a single health system to build evidence on the current demographics, amount of training, and TL practices of 3 levels of frontline nurse leaders. The demographics of the frontline nurse leaders indicate that promotion and growth are occurring within the organization, as each level of leadership is more experienced, tenured, educated, and trained and has a larger span of control. In addition, the leaders report higher self-perceived leadership behaviors (total LPI scores) with each level of leadership. This would indicate growth and confidence as the leader advances in his/her career. The nurse leaders at each level rated their highest TL behavior as enabling others to act, aligning with current research. 1 Behaviors that enable others to act as leaders include fostering collaborations, sharing power and decision making, and ensuring individuals grow in their roles. 12 Nurse leaders who Table 3. Independent Predictors of Leadership Practices LPI Total Challenge Inspire Model Enable Encourage Title 5.66 a ( ) 2.24 a ( ) 2.19 a ( ) V 0.89 a ( ) V Training V V V 0.34 a ( ) V V Education 3.86 b ( ) 1.22 a ( ) 1.21 b ( ) V V V Coefficient (confidence interval). Stepwise regression modeling including demographics (title, age, years of nurse experience, years of frontline leadership experience, certification, and education) and total amount of training classes. a P G.01. b P G.05. JONA Vol. 44, No. 3 March

5 engage in shared governance, support evidence-based practice, or mentor their employees can enable their nurses and act as transformational leaders. Interestingly, nurses at all 3 levels of leadership in the study scored similarly on the encourage the heart subscale. These behaviors involve rewarding and recognizing employees through meaningful appreciation and finding ways to revitalize individuals to foster commitment to work. In addition, nurse leaders self-report higher levels of TL behaviors above averages published through the LPI normative database. 25 Three significant predictors of leadership behaviors emerged: title, training, and education, indicating areas that could potentially help nurse leaders increase their leadership behaviors. Because nurses demographics, amount of training, and self-perceived leadership practices increased with each level of leadership, title is most likely a proxy for the experience, training, and knowledge gained as a nurse advances his/her career. In addition, title had the largest contribution in raising leadership behaviors in overall LPI score and 3 of the 5 subscales. Thus, the findings indicate nurse leaders are demonstrating higher levels of leadership as they are promoted into higher leadership positions; however, the question remains as to whether they struggle initially when they orient and attain the additional leadership practices needed. Although nurses in this study received considerable training, training was a significant predictor of only the model the way subscale. Leadership practices related to modeling the way include role modeling behaviors, goal setting, and creating an environment of mentorship. 12 Nurse leaders in the study demonstrated increased modeling the way TL practices after attending the formal training program. In general, didactic leadership training programs focus on goal setting and attainment and role modeling leadership behaviors. Thus, organizations looking to increase nurse leader s behaviors in this area potentially could benefit from concentrating on a formal leadership training program. Other leadership development programs have been found to raise additional TL practices through purposeful facilitation focusing on specific behaviors the organization desires to improve 26 ; thus, it is important for an organization to evaluate the needs of their leaders when developing a leadership development program. Somewhat unexpectedly, education was a significant predictor of the total LPI score and the challenge the process and inspire a shared vision subscales, while controlling for the nurse s title. Education, measured as a nurse attaining an advanced degree (ie, moving from an associates to bachelors or a bachelors to a masters degree), could help increase the nurse s ability to think innovatively and take risks. Nurses who have a clear vision can see the larger picture of their future in nursing and aspire to take others along with them. In addition, nurses who seek out new opportunities to challenge themselves are also empowered to lead their employees to explore new opportunities and growth. 12,19 The findings suggest that nurse leaders could benefit in developing TL practices in these areas through advanced degree attainment. Limitations The survey was cross-sectional and represented selfperceived leadership practices of nurse leaders. Thus, it is unknown whether nurses attain leadership positions as a result of strong leadership practices or develop strong leadership practices after attaining a leadership position. In addition, leaders with shorter tenure in their position may not have completed as many training courses as leaders who have been in the organization longer; however, the large sample size helped reduce this variation. While doctoral education has been shown to be positively associated with TL, 1 there was not a sufficient sample size of doctoralprepared nurses in the study to analyze this level of education independently. Finally, training and development programs intended to build leadership often focus on the needs of the organization and are not specifically intentioned to build TL style, as was the case with the health system under study. Conclusions Organizations can develop the TL styles of their frontline nurse leaders through a variety of methods, recognizing that formal training programs can increase behaviors that help nurses model the way and higher educational degree attainment can increase the nurse s ability to envision the future, think innovatively, and enact change. Nurse executives can use the findings to support leadership development through formal education and leadership training, focusing on advancing the priorities and leadership needs within their organization. Findings from the research study are being used within the health system to create a multifaceted approach to developing nurse leaders that addresses training and education. With guided development, nurses can have a smoother transition to leadership roles, ultimately reducing turnover and increasing satisfaction, retention, and work-life balance. Continuing research on the effects of TL on nurse and patient outcomes can help guide organizations on the benefit of investing time and resources into developing frontline nurse leaders. 162 JONA Vol. 44, No. 3 March 2014

6 References 1. Clavelle JT, Drenkard K, Tullai-McGuinness S, Fitzpatrick JJ. Transformational leadership practices of chief nursing officers in Magnet A organizations. JNursAdm. 2012;42 (Suppl 10):S3. 2. Heuston MM. Transformational leadership skills of successful nurse managers. J Nurs Adm. 2011;41(6): Tourangeau AE, McGilton K. Measuring leadership practices of nurses using the Leadership Practices Inventory. Nurs Res. 2004;53(3): Hutchinson M, Jackson D. Transformational leadership in nursing: towards a more critical interpretation. Nurs Inq. 2013; 20(1): Fennimore L, Wolf G. Nurse manager leadership development. JNursAdm. 2011;41(5): Bass BM, Avolio BJ. Improving Organizational Effectiveness Through Transformational Leadership. Thousand Oaks, CA: Sage Publications, Inc; Bass BM. Two decades of research and development in transformational leadership. Eur J Work Organ Psychol. 1999; 8(1): Cummings GG, MacGregor T, Davey M, et al. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Int J Nurs Stud. 2010; 47(3): Burns JM. Leadership. New York: Harper & Row; Bass BM. Leadership and Performance Beyond Expectations. New York: Free Press; Bass BM, Avolio BJ. Transformational leadership and organizational culture. Public Adm Q. 1993;17(1): Kouzes J, Posner B. The Leadership Challenge. San Francisco, CA: Jossey-Bass Publishers; Marquis BL, Huston CJ. Leadership Roles and Management Functions in Nursing: Theory and Application. 6th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; Avolio BJ, Walumbwa FO, Weber TJ. Leadership: current theories, research, and future directions. Annu Rev Psychol. 2009;60(1): Kouzes JM, Posner BZ. The Five Practices of Exemplary Leadership. 2nd ed. San Francisco, CA: Pfeiffer; Curtis E, O Connell R. Essential leadership skills for motivating and developing staff. Nurs Manage. 2011;18(5): Luzinski C. Transformational leadership. JNursAdm. 2011; 41(12): Wong CA, Cummings GG. The relationship between nursing leadership and patient outcomes: a systematic review. J Nurs Manag. 2007;15(5): Spence Laschinger HK, Wong CA, Grau AL, Read EA, Pineau Stam LM. The influence of leadership practices and empowerment on Canadian nurse manager outcomes. J Nurs Manag. 2012;20(7): Evans ML. Developing the role of leader. In: Yoder-Wise PS, ed. Leading and Managing in Nursing. 4thed.St.Louis,MO: Mosby Elsevier; 2007:30-31, Krugman M, Smith V. Charge nurse leadership development and evaluation. J Nurs Adm. 2003;33(5): Wolf GA, Bradle J, Greenhouse P. Investment in the future: a 3-level approach for developing the healthcare leaders of tomorrow. J Nurs Adm. 2006;36(6): Conley SB, Branowicki P, Hanley D. Nursing leadership orientation: a competency and preceptor model to facilitate new leader success. J Nurs Adm. 2007;37(11): SPSS Inc. SPSS Chicago, IL: SPSS Inc; Kouzes J, Posner B. LPI online normative database. December Updated Research-section-Our-Authors-Research-Detail/lpi-onlinenormative-database-december-2011.aspx. Accessed April 25, Martin JS, McCormack B, Fitzsimons D, Spirig R. Evaluation of a clinical leadership programme for nurse leaders. J Nurs Manag. 2012;20(1): JONA Vol. 44, No. 3 March

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