A Comparison of Leadership Development Interventions: Effects on Nurse and Patient Outcomes Lisa Rowen, DNSc, RN, FAAN Senior Vice President and Chief Nurse Officer Karen Doyle, MBA, MS, RN, NEA-BC Vice President, Nursing and Operations R Adams Cowley Shock Trauma Center University of Maryland Medical Center
Welcome Disclosures Today s presenters do not have any relevant financial interests or endorsement of products. Participants must attend the entire session(s) in order to earn contact hour credit. Continuing Nursing Education credit can be earned by completing the online session evaluation. The American Organization of Nurse Executives is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation.
Study Team Principal Investigator Lisa Rowen, DNSc, RN, FAAN Co-Investigators Karen Doyle, MBA, MS, RN, NEA-BC Kristin L. Seidl, PhD, RN Patricia Woltz, MS, RN, PhD(c) Karen Johnson, PhD, RN
University of Maryland Medical Center Located in downtown Baltimore, founded in 1823, and one of the nation s oldest teaching hospitals Academic, quaternary hospital with vibrant Health Sciences campus Schools of Nursing, Pharmacy, Medicine, Social Work, Dentistry, Law and Physical Therapy across the street Magnet designated hospital National Cancer Institute designated Cancer Center Leapfrog designated Hospital of the Decade for safety and quality (Leapfrog Group) To apply, visit jobs.umm.edu ~39,000 Admissions ~800 Beds ~400 Intensive Care Beds (50%) 11 Intensive Care Units 9 Intermediate Care Units Variety of Acute Care Units ~66,000 Emergency Visits ~176,000 Outpatient Visits 21,000 Surgical Procedures ~7,500 Employees 77 Clinical Nurse Leaders 1,135 Physicians > 200 Advanced Practice Nurses To visit our Facebook page, go to https://www.facebook.com/marylandnursing
Objectives Describe the impact of leadership development strategies on nurse and patient outcomes Identify the implications of this research for future leadership development initiatives
Background Transformational leadership includes: Establishing and sharing a clear vision Enabling others to act Modeling desired behaviors Healthy work environment includes: Satisfied nurses Communication openness Systems to prevent adverse events
Background CNO leadership style has demonstrated positive influence on: Nursing performance Work environment Patient outcomes (Brady Germain & Cummings, 2010; Wong & Cummings, 2007; Shirey, 2006) Nursing leadership visibility and accessibility is expected by today s direct care nursing staff (Germain, P. & Cummings, G. (2010). The influence of nursing leadership on nurse performance: A systematic literature review. Journal of Nursing Management, 18, 425-39)
Background Mechanisms by which leadership is related to outcomes are indirect Leadership influences work context and nurse behavior Nurse performance promotes positive patient outcomes These mechanisms are not well understood Methods to develop transformational leaders have not been well examined
Purpose The purpose of this study is to explore the effect of different interventions of leadership development for unit managers on nurse and patient outcomes over time
Conceptual Framework Complexity theory suggests that all organizations are complex adaptive systems (CAS) CAS s self-organize Self-organization is the adjustment of behavior needed to cope with changing internal and external demands 3 system parameters are key: Rate of information flow Nature of connections Diversity of cognitive schema
Model
Model
Specific Aims Specific Aims: Assess the impact of a didactic classroom leadership development program on nurse and patient outcomes over time Assess the impact of senior nursing leadership walking rounds on nurse and patient outcomes over time Assess the impact of a combination of didactic classroom and senior nursing leadership walking rounds development programs on nurse and patient outcomes over time Describe the mechanisms by which certain leadership practices (communication openness, participation in decision making and relationship-oriented leadership) contribute to nurse satisfaction and patient outcomes
Methods Four intervention groups: Leadership development class Senior leadership walking rounds Class and walking rounds No intervention (control) 16 nurse managers randomly allocated based on type unit (ICU, IMC, acute surgical or medical units) Interventions took place after baseline data collection Measurements at baseline, 3 and 6 months
Outcomes Measures (# items) Communication openness Hospital Survey on Patient Safety Culture, Section C (3) Participation in decision-making Nurse Quality Indicators: decision making (7), nursenurse interaction (6), nurse-physician interaction (6), autonomy (7), and professional status (6) Relationship oriented leadership Hospital Survey on Patient Safety Culture, Section B (2) and Nurse Quality Indicator: leadership (5) Job enjoyment Nurse Quality Indicator: job enjoyment (7) RN satisfaction with job Nurse Quality Indicator: decision making (7) Patient satisfaction Fall rate Pressure ulcer incidence CLABSI HCAHPS nurse communication with patient (3), overall rating of hospital (1) Number of falls/1000 patient days Incidence of hospital acquired pressure ulcers/patient days/3 months Number of CLABSI/1000 device days
Intervention - Classroom Led by CNO and VP, Trauma Nursing and Operations Taught by nurse and business experts in the organization 12 hours over 2 days
Didactic Content Transformational leadership Leadership competencies Patient satisfaction Shared governance Staff satisfaction Service recovery Rounding Environment of care Nurse sensitive indicators Data sources
Intervention Leadership Rounds Led by CNO or VP, Trauma Nursing and Operations Monthly during the first 3 months Visit unit of enrolled manager and round with manager, clinical leaders and staff at the bedside
Rounding Content Focus conversation on establishing priorities and best practice CNO/VP teaches through questions: What are your safety concerns? If you could change one thing on this unit, what would it be? Let s look at the fall risk assessment. Are the interventions consistent with the risk category? How are you involved in decisions that affect your practice?
Analysis Nurse satisfaction and patient satisfaction (continuous outcome data) were analyzed using linear mixed models (LMM) CLABSI, pressure ulcer, and fall rates (count data) were analyzed using generalized linear mixed models (GLMM) Significance p <.05
Results 15 of 16 nurse managers completed the study. One manager dropped out when she relocated 3 months into the study
Class Evaluation Participants rated the program from 1 (low) to 5 (high): Speaker effectiveness 4.5 Content objectives 4.9 Teaching methods 4.5 Translated research data to practical application 4.4 Will assist me in patient care 4.9 Motivated me to modify my practice behavior 4.9
Class Evaluation: Write-in Comments The small group allowed for easy conversation and discussions. Review of reports was helpful - never understood all of it before. Overall this was an excellent presentation. Additional knowledge shared will help me become a better manager.
Evaluation - Rounding Facilitated trusting relationship between senior nurse leader and manager Senior Nurse Leader role modeled speaking with patients, family members and staff Senior Nurse Leader and Nurse Manager were able to jointly identify and address issues raised Senior Nurse Leader was able to evaluate and coach Nurse Manager behavior Nurse Managers, staff, patients and families repeatedly offered positive feedback about Senior Nurse Leader participation in rounds
Results - Nurse Satisfaction 610 nurses were invited by email to participate 255 responses (41%) at baseline 131 responses (21%) at 3 months 134 responses (22%) at 6 months Taking into account differences at baseline, there were no meaningful differences between the groups over time
Communication Openness Communication Openness improved over time in all groups, even in the control group. (F(6,511)=2.49, p=.022)
Patient Overall Satisfaction with Hospital Taking into account differences at baseline, there were no statistically significant differences between the groups over time 100 Baseline 3 Months 6 Months Percent Checking Top Box for Overall Patient Satisfaction 90 80 70 60 50 40 30 20 10 0 Control Didactic Walking Rounds Combined Group F(6,22)=2.2, p=.083)
Results Nurse Sensitive Outcomes Taking into account differences at baseline, there were no significant differences between the groups over time CLABSI Fall Rates Hospital acquired pressure ulcers
Conclusions Based on positive feedback from staff, patients, families and nurse manager participants, we believe that the transformational leadership interventions were helpful, effective and developed trusting relationships Senior Nurse Leaders noted a positive change in the comfort level, sophistication and insight of Nurse Managers from the first to final rounding experience However, no measureable change in the aggregated nurse satisfaction or patient outcome measures were detected in this study
Discussion Chaos Theory is supported Many variables other than transformational leadership interventions effect nurse and patient outcomes Another organizational focus may have diverted the attention of nurse managers from regular rounding Measurement of the wrong variables Improvement in Communication Openness was a positive finding, as it may begin to explain the indirect mechanisms by which Transformational Leadership impacts patient outcomes No measurement to account for relationship with nurse manager
Discussion Empirical outcome measurement as suggested for Magnet designation may not be a good measure of transformational leadership intervention Nurse sensitive outcomes are likely too insensitive to change that can be attributed to implementation of transformational leadership interventions within a hospital Outcome measures for intervention effectiveness need to elucidate the mechanisms by which interventions work
Recommendations Better research measures need to be identified to evaluate the usefulness of transformational leadership interventions Use of didactic and rounding teaching interventions by senior nursing leadership with nurse managers is valuable for the strategic growth and development of nurse managers
Acknowledgements This study was funded by a 2010 Research Seed Grant from the American Organization of Nurse Executives