Leadership and pre-registration nurse education

Transcription

1 C Watts and J Gordon, 2012 Key findings Leadership and pre-registration nurse education This rapid review analysed studies from nursing literature from to answer the question: What approaches are being taken to teach and grow leadership skills in pre-registration nurse education in the UK? The evidence base on effectiveness of nurse leadership skills teaching is limited, with a lack of consensus on what constitutes effective leadership in nursing, and the design of evaluations of approaches described in existing studies being problematic to generalise across the UK context. Many studies draw on existing understanding of key leadership skills in developing their leadership learning programmes, but there is no consistent core set of skills, and some programmes conflate leadership and management skills. Applying leadership skills, values and attitudes in practice is a key practical element to learning. Student leadership of peers has been a well-evaluated approach in the US, with beneficial learning outcomes for both senior student leaders and their junior student peers. Leadership skills are integral to the nursing role and should similarly be embedded throughout pre-registration nurse education, rather than confined to a single dedicated programme of study. Student exposure to skilled, positive leadership role-modelling significantly enhances the learning experience, although providing access to leaders is problematic at organisational level, particularly in the context of a changing UK workforce. Reflective learning is recognised as both a leadership attribute and a valuable learning technique that reinforces the blending of theoretical and applied learning. There are synergies with the development of emotional intelligence and leadership skills, although more understanding is needed of their relationship and how this might translate into learning programmes. Introduction This report presents the findings of a rapid review giving an overview of the evidence addressing the provision of leadership skills in pre-registration nurse education. The review question was: What approaches are being taken to teach and grow leadership skills in preregistration nurse education in the UK? The rapid review took place over a three-week period, and an appropriate five year scope was determined for this timeline.

2 To answer this question, a literature search of material from was carried out using British Nursing Index, CINAHL 1 and Medline databases. 21 papers were identified and reviewed. As few studies were UK-based, international literature was also considered for the purpose of this review, particularly a number of studies from the US. Only English-language studies were considered. While there is broader discussion around approaches to teaching effective leadership skills, the focus of this review is the pre-registration nurse education context, and therefore the majority of identified studies were specifically from nursing-related literature. Overview of the evidence The evidence base on the effectiveness of nurse leadership skills teaching is limited. In particular, there is a lack of understanding of how successfully learning translates into practice following graduation, with any studies that do undertake pre-post evaluation doing so within the confines of undergraduate experience itself. The literature search identified no systematic reviews reflecting the specific review question, although there have been systematic reviews conducted outside of the pre-registration nurse education context (Wong and Cummings, 2007; Pearson et al, 2007). Outside of the nursing context, there have been systematic reviews into the effectiveness of leadership development (Leskiw and Singh, 2007; Hartley and Hinksman, 2003), and select findings from these are used in this review to triangulate findings. Most studies included in this review were of non-experimental, cross-sectional or descriptive design, usually describing the implementation of a leadership skills training initiative. Varying detail around evaluation of these initiatives makes generalising findings problematic. Noticeably absent from the literature was an understanding from nurse leaders of how their undergraduate leadership training proved valuable in practice. Further more in-depth investigation may identify some evidence around this area of interest. Structure of the report Findings from the review are divided into four sections below. What does good look like? Discussion of what is meant by effective leadership, its definition and attributes. What works where evidence from the literature demonstrates effective provision of leadership skills in pre-registration nurse education. What is promising learning from the literature indicating potential good approaches to providing leadership skills in pre-registration nurse education. What are the challenges and barriers impediments to providing leadership skills in pre-registration nurse education. What does good look like? Understanding of effective leadership Provision of high quality nursing care, together with the nurturing of a culture of innovation and support, is reliant on effective leadership skills. Despite calls for the building of 1 Cumulative Index to Nursing and Allied Health Literature

3 leadership capacity as a priority for the profession, it is widely accepted that leadership in nursing in an under-researched area (Walker et al, 2011; Zilembo and Monterosso, 2008). This review demonstrates that this paucity extends to the pre-registration nurse education context. There are some demonstrations of the importance of effective leadership in nursing practice outside of the pre-registration education context. Wong and Cummings (2008) found evidence of associations between positive leadership, increased patient satisfaction and reduced adverse events, although findings relating leadership to patient mortality were inconclusive. Pearson et al (2007) found relations between a healthy work environment and positive leadership approaches, although much of the identified literature in this review was of a descriptive nature. Definition Articulating what is meant by effective leadership is also problematic in the absence of a single definition of leadership (Curtis et al, 2011a). Few national policy documents actually define what constitutes effective leadership although there are frequent calls for the necessity of effective leadership in order to achieve quality nursing care (Curtis et al, 2011b). Skills and competences Many of the approaches to provision of leadership skills in pre-registration nurse education described in the literature base development of learning programmes on an initial understanding of leadership skills and competences 2. Skills and competences described in these studies are grouped below. Some authors include management-related skills/activities when discussing nurse leadership attributes. Interpersonal: such as conflict resolution, team skills and delegation (Zilembo and Monterosso, 2008; Heller et al, 2004). Supportive: compassion and supportive attitudes (Zilembo and Monterosso, 2008), awareness of the perceptions of others, showing a willingness to make changes, striving to understand other people, and encouraging others (Benson et al, 2012). Communication: skills associated with emotional intelligence such as awareness of how one communicates with others and listening attentively for meaning and feelings (Benson et al, 2012; Zilembo and Monterosso, 2008; Heller et al, 2004). Management: finance, strategic planning and human resources (Klienmann, 2003), decision making, problem solving and effective staffing strategies (Care and Udod, 2003), crisis management, time management (Heller et al, 2004), and systems theory (Jones and Sackett, 2009). Knowledge: economics and financial management of health care delivery systems and managed care; knowledge of technology, patient safety, resource management, and business or administrative practices; organisational theory and change theory; 2 Kleinmann (2003) surveyed 128 nurse managers and nurse executives to explore their perspectives of competences required in their roles. A further survey of nurse managers by Care and Udod (2003) identified competences in leadership and human skills. Heller et al (2004) report on an innovative course on nursing leadership in a US-based pre-registration programme that determined core knowledge competencies. Zilembo and Monterosso (2008) surveyed 23 pre-registration nursing students in Australia to identify skills fostered in students by nurse leaders. Benson et al (2012) looked at how self-assessed leadership characteristics in 52 Canadian nursing students.

4 types of leadership styles; roles of gender and diversity in nursing leadership; and responsibility to the profession (Heller et al, 2004). What works? None of the studies identified through the literature search were of a design that could demonstrate causality. While many studies were well received and evaluated by students, testing of their effectiveness was usually through a cross-sectional self-reported approach, and it remains unclear as to how this learning subsequently proved beneficial in practice. A lack of a universal definition of effective leadership also impacts the robustness and generalisability of findings. Leadership skills in practice Leadership development literature highlights the importance of applying learning in practice. (Hartley and Hinksman, 2003). Giving students the requisite skills to think and behave as leaders during pre-registration education supports these values and attitudes in being retained, normalised and carried on throughout nurses subsequent professional careers. Leadership training should be context specific for the nursing profession, and include practical strategies for students to adopt and assimilate into practice (Zilembo and Monterosso, 2008). A practical element to learning leadership skills, often through senior student nurses receiving hands-on experience of applying leadership skills with their more junior peers, was a commonly studied approach in the US. Peer leaders in these studies facilitated collaborative learning, including serving as a source of motivation and encouragement (Bensfield et al, 2008) and teaching peers skills such as time management, prioritisation, skills technique, task completion and documentation (Kling, 2010). Peer leaders themselves learned positive leadership and learning skills, including interpersonal skills, leadership behaviours, facilitating a positive learning environment (Bensfield et al, 2008), delegation to and supervision of nursing staff providing patient care (Lekan, 2010; Kling, 2010), effective communication, leadership, management and learner styles, instructional strategies and proactive problem solving (Kling, 2010; Daley, 2008). Leadership by example Effective leaders have skills and knowledge to motivate staff, encourage and support collaboration, and facilitate change. Transformational leadership is repeatedly cited as an effective leadership approach, with its emphasis on development of supportive relationships that enable staff to enjoy meaningful work, communicate ideas and foster collaborative working (Walker et al 2011; Curtis et al, 2011b; Bolkan and Goodboy, 2009). Exposure to effective leadership influences undergraduate clinical learning and may influence learning throughout the professional career (Walker et al, 2011). Staff supported by effective leaders are increasingly likely continually to engage in learning (Cummings et al, 2010; Duffield et al, 2009). Observation of, and working under, staff modelling positive leadership skills enhance the learning experience. There is a relationship between student self-efficacy and their perception of professional behaviour and structural empowerment (the combination of organisational strategies that allow individuals within the environment to work in an

5 empowered manner) (Livsey, 2009). Students experiencing positive leadership rolemodelling reported an increase in their own leadership attributes (Hendricks et al, 2010; Schoenfelder and Valde, 2009). There are significant changes in key leadership skills and behaviours in students exposed to positive leadership attributes in their learning environment (Hendricks et al, 2010). What is promising? Reflective learning Reflection is referred to in the literature as both as an approach to learning and a leadership skill. Reflective learning is recognised in leadership development literature as having benefits to learning leadership skills, including fostering collaborative approaches to problem solving (Hartley and Hinksman, 2003) and supporting self-perception of leadership skills (Eid and Johnsen, 2008). Self-awareness and insight into strengths and weaknesses is a key quality of effective leadership (Hendricks et al, 2009; Heller et al, 2004). Providing opportunities for nurses to reflect and apply new knowledge gained from leadership training into practice is a crucial element of reinforcing theoretical learning, and supports the importance of having applied leadership training within pre-registration nurse education (Lekan, 2011; Paterson et al, 2010; Hendricks et al, 2009; Heller et al, 2004). Emotional intelligence Emotional intelligence (EI) is considered a key skill in nurse leaders, with suggestions EI should be an integral part of nurse education (Benson et al, 2012; Beauvais et al, 2011). Nursing education should include strategies to develop people-oriented leadership skills essential to delivering effective nursing leadership (Duygulu et al, 2011). EI significantly relates to total nursing performance (teaching and collaboration, planning and evaluation, interpersonal skills and communication, professional development) (Beavais et al, 2011) and task-oriented leadership (Duygulu et al, 2011). No positive relationship has been demonstrated specifically between EI and leadership skills. There may be a disparity between leadership and EI abilities that goes beyond nurse education (Beavais et al, 2011). However, positive correlations have been found between changes in EI and changes in leadership in nurse students, with many of the behaviours demonstrated in a leadership tool also behaviours indicated in EI. These include: awareness of how you communicate with others, listening attentively for meaning and feelings, awareness of the perceptions of others, showing a willingness to make changes, striving to understand other people, and encouraging others (Benson et al, 2012). What are the challenges and barriers? Access to leaders Leadership development literature demonstrates that time constraints may impact on ability to engage in peer coaching (Ladyshewsky, 2007). Presence or otherwise of effective leadership in pre-registration clinical learning many help or hinder transference of learning to the clinical setting. However, providing access to leaders is problematic, principally at an organisational level (Walker et al, 2011; Cummings et al, 2010; Hendricks et al, 2010; Duffield et al, 2009; Schoenfelder and Valde, 2009).

6 Structural changes in ward management have shaped both nurse education and practice, with subsequent absence of leadership from senior nurses in practice leading to leadership for learning being increasingly taken on by mentors (Allan et al, 2008). Recent changes in nurse education have impacted leadership of student nurses learning in clinical practice. A survey of four English higher education institutions between 2006 and 2007 concluded link lecturer presence in clinical areas was being reduced, and practice nurse involvement in student education limited. Ward managers led education activities at ward level, rather than with the individual student, potentially compromising access to and tacit learning from skilled, positive leadership (O Driscoll et al, 2009). Defining and supporting the leadership role Training and support for clinical supervisors is crucial in avoiding confusion around their leadership role in clinical learning (Walker et al, 2011; O Driscoll et al, 2010). Some staff may unexpectedly find themselves leading learning provision for students, including acting as a role model in terms of conveying leadership skills. A potentially reduced presence of link lecturers may lead to an emphasis on practice educator nurses to foster a high quality learning environment, although some of these nurses may not envisage themselves having a broader role in leading pre-registration learning (O Driscoll et al, 2010). A supportive organisational culture is important in developing leaders and improving leadership, and a healthy work environment may have a positive effect on nurse retention (Curtis et al, 2011b). Further exploration is required as to how this view may translate into the higher education environment. Integrating leadership skills into pre-registration learning Leadership development literature demonstrates that embedding leadership skills learning into organisational culture is a key factor in successful implementation of leadership programmes (Leskiw and Singh, 2007; Hartley and Hinksman, 2003). This integration extends to the pre-registration nurse education context. Leadership should not be viewed as an optional role or function for nurses, and all nurses should have the necessary leadership skills to apply these in all aspects of their work. Leadership skills should be taught longitudinally through the continuum, rather than last semester of study, ensuring students have the opportunity to practice these skills in a clinical setting, and preparing nurses to see practice as part of leadership rather than leadership as part of practice (Curtis et al, 2011a; Jones and Sackett, 2009). The necessity of leadership skills is not confined to management roles. Any person providing assistance to others is taking on a leadership role; therefore, a student nurse is a leader to patients and clients (La Monica, 1994). Lack of leadership skills provision There may be a gap between educational preparation and complex practice settings, leaving nurses unprepared to provide effective frontline leadership (Heller et al, 2004). Primary degrees may not sufficiently prepare nurses for the application of leadership in their professional practice, and consequent shortfall in leadership skills falls to health care organisations to make up through promoting and developing leadership programmes (Curtis

7 et al, 2011b). The literature examined here does not refer to any quantified understanding leadership skills provision in UK nurse education. References Allan, H., Smith, P. & Lorentzon, M. (2008) Leadership for learning: a literature study of leadership for learning in clinical practice. Journal of Nursing Management, 16, Beauvais, A., Brady, N. & O'shea, E. (2011) Emotional intelligence and nursing performance among nursing students. Nurse Education Today, 31, Bensfield, L., Solari-Twadell, P. A. & Sommer, S. (2008) The use of peer leadership to teach fundamental nursing skills. Nurse Educator, 33, Benson, G., Martin, L., Ploeg, J. & Wessel, J. (2012) Longitudinal study of emotional intelligence, leadership, and caring in undergraduate nursing students. The Journal Of Nursing Education, 51, Bolkan, S. & Goodboy, A. (2009) Transformational leadership in the classroom: fostering student learning, student participation, and teacher credibility. Journal of Instructional Psychology, 36, Care, W. & Udod, S. (2003) Perceptions of first-line nurse managers: what competencies are needed to fulfill this role? Nursing Leadership Forum, 7, Cummings, G., Macgregor, T., Davey, M., Lee, H., Wong, C. & Lo, E. (2010) Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Journal of Nursing Studies, 47, Curtis, E., De Vries, J. & Sheerin, F. (2011a) Developing leadership in nursing: exploring core factors. British Journal of Nursing, 20, Curtis, E., Sheerin, F. & De Vries, J. (2011b) Developing leadership in nursing: the impact of education and training. British Journal of Nursing, 20, Daley, L., Menke, E., Kirkpatrick, B. & Sheets, D. (2008) Partners in practice: a win-win model for clinical education. Journal of Nursing Education, 47, Duffield, C., Roche, M., O'brien-Pallas, L., Catling-Paull, C. & King, M. (2009) Staff satisfaction and retention and the role of the nursing unit manager. Collegian, 16, Duygulu, S., Hicdurmaz, D. & Akyar, I. (2011) Nursing students' leadership and emotional intelligence in Turkey. The Journal Of Nursing Education, 50, Eid, B.H. and Johnsen, P.J. (2008) Growing transformational leaders: exploring the role of personality hardiness. Leadership and Organization Development Journal, 4, Hartley, J. & Hinksman, B. (2003) Leadership development: a systematic review. A report for the NHS Leadership Centre. Warwick Institute of Governance and Public Management: University of Warwick, Coventry. Heller, B., Esposito-Herr, M. & Tom, S. (2004) Educating nurses for leadership roles. Journal of Continuing Education in Nursing, 35,

8 Hendricks, J. M., Cope, V. C. & Harris, M. (2010) A leadership program in an undergraduate nursing course in Western Australia: building leaders in our midst. Nurse Education Today, 30, Jones, J. M. & Sackett, K. (2009) Integrating leadership and management content across the curriculum: a 3-course approach. Nurse Educator, 34, Kleinman, C. (2004) Leadership: a key strategy in staff nurse retention. Journal of Continuing Education in Nursing, 35, Kling, V. G. (2010) Clinical leadership project. The Journal Of Nursing Education, 49, Ladyshewsky, R.K. (2007) A strategic approach for integrating theory to practice in leadership development. Leadership and organisational development Journal, 28, La Monica, E. (1994) Management in health care: a theoretical and experiential approach, Hampshire, Macmillan Press Ltd. Lekan, D., A., Corazzini, K., N., Gilliss, C., L. & E. (2011) Clinical leadership development in accelerated baccalaureate nursing students: an education innovation. Journal of Professional Nursing, 27, Leskiw, S.L. & Singh, P. (2007) Leadership development: learning from best practices. Leadership and Organization Development Journal, 28 (5), Livsey, K. (2009) Structural empowerment and professional nursing practice behaviors of baccalaureate nursing students in clinical learning environments. International Journal of Nursing Education Scholarship, 6, O'Driscoll, M., Allan, H. & Smith, P. (2010) Still looking for leadership - who is responsible for student nurses' learning in practice? Nurse Education Today, 30, Paterson, K., Henderson, A. & Trivella, A. (2010) Educating for leadership: a programme designed to build a responsive healthcare culture. Journal of Nursing Management, 18, Pearson, A., Laschinger, H., Porritt, K., Jordan, Z., tucker, D. & Long, L. (2007) Comprehensive systematic review of evidence on developing and sustaining nursing leadership that fosters a healthy work environment in healthcare. International Journal of Evidence-Based Healthcare, 5, Schoenfelder, D. & Valde, J. (2009) Creative practicum leadership experiences in rural settings. Nurse Educator, 34, Spellman, R. (2011) Hit the ground running. Nursing Standard, 25, 61. Walker, R., Cooke, M., Henderson, A. & Creedy, D., K. (2011) Characteristics of leadership that influence clinical learning: A narrative review. Nurse Education Today, 31, Wong, C.A. & Cummings, G.G. (2007) The relationship between nursing leadership and patient outcomes: a systematic review. Journal of Nursing Management, 15,

9 Zilembo, M. & Monterosso, L. (2008) Nursing students' perceptions of desirable leadership qualities in nurse preceptors: a descriptive survey. Contemporary Nurse: A Journal for the Australian Nursing Profession, 27,