Journal of Nursing Management, 2015, 23, 1086–1093
The impact of a leadership development programme on nurses’ self-perceived leadership capability KARYN PATERSON B H S c BURMEISTER R N , P h D 3
(Nurs) MEd
1
, AMANDA HENDERSON
RN, RM, PhD
2
and ELIZABETH
1
Nurse Educator, 2Nursing Director (Education) and 3Nurse Researcher, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Australia
Correspondence Amanda Henderson Nursing Practice Development Unit Princess Alexandra Hospital Ipswich Road Woolloongabba 4102 Queensland Australia E-mail: Amanda_Henderson@ health.qld.gov.au
PATERSON K., HENDERSON A. & BURMEISTER E.
(2015) Journal of Nursing Management 23, 1086–1093. The impact of a leadership development programme on nurses’ selfperceived leadership capability Aim This paper reports on the outcomes of a locally designed educational programme to support leadership capability of junior registered nurses. Background The Developing Leader Programme is an in-house programme delivered in three face-to-face workshops, comprising self-directed reflective and application activities. Method Surveys were used to evaluate self-perceived leadership capability over a 9month period. The survey comprised a Leadership Capability Instrument adapted from two existing tools. Participants completed surveys at the commencement of the programme, after the third and final workshop and approximately 6 months afterwards. In addition, examples of descriptive accounts of programme activities submitted by individual participants were included to enrich data. Results Of 124 participants, 79 completed surveys at the first workshop, 28 at the final workshop and 31 were returned 6 months after completion of the programme. Mean scores for each area of leadership capability significantly improved throughout the duration of the programme (P < 0.001). Participants also indicated a willingness to enact leadership behaviours through reported activities. Conclusions Survey responses indicated that participants perceived improved leadership capability after completing the Developing Leader Programme. Implications for nursing management Early educational intervention to facilitate the development of leadership skills as well as clinical skills in junior registered nurses can assist with how they interact with the team. Participation of junior registered nurses in a locally designed leadership programme can assist them to develop leadership behaviours for everyday practice. Keywords: evaluation, nursing leadership, nursing practice, practice leadership
Accepted for publication: 30 June 2014
Introduction Acute health care environments are characterised by a frenetic pace, high patient acuity, a demand for quality and safety, and increasingly limited lengths of stay (Dyess & Parker 2012). The literature continues to support the need for effective leadership in such environments, 1086
because leadership has been shown to be important in establishing and maintaining team relationships that foster high-quality and safe nursing environments conducive to nurses voicing concerns and asking for help (Squires et al. 2010), attracting and retaining staff, and improving staff satisfaction (Swearingen 2009, Dignam et al. 2011), providing patient-centred, evidence based DOI: 10.1111/jonm.12257 ª 2014 John Wiley & Sons Ltd
Impact of a leadership development programme
and outcome oriented care (Martin et al. 2012) and managing change (Perry 2012). The concept of clinical leadership at the point of care is an area of increasing interest in health-care environments (Patrick et al. 2011). Leadership at all levels of nursing, including informal leadership practised by clinicians is important in this regard (Swearingen 2009). Clinical leadership may be defined as nurse behaviours that provide direction and support to patients and the health-care team in the delivery of care (Patrick et al. 2011). The primary focus of clinical leadership is the patient rather than the organisation, and persuasion and collaboration rather than structural power are used to plan and enact change (Bender et al. 2012). In championing this concept of leadership at all levels of nursing, Morton (2012) espouses the significance of the ‘inner leader’ of the bedside nurse who models and empowers change, and who brings knowledge and understanding to individual practice and team collaboration. In Australia, there is an explicit requirement of the national competency standards for registered nurses that all registered nurses take a leadership role in the coordination of nursing and health care to facilitate optimal health outcomes (Nursing & Midwifery Board of Australia 2006).
Origin of the programme Students and nurses beginning practice are generally well supported to acquire and practise clinical skills; however, fewer opportunities are provided for them to gain and practise leadership skills. Many of the available leadership programmes are designed to prepare nurses for leadership roles once they are formally appointed into leadership positions, and are aimed at the nurse unit manager level or higher (Paterson et al. 2010). Clinical leadership refers to nurses drawing on their clinical expertise to make decisions and initiate change to improve patient wellbeing. Such leadership is heavily dependent on successful communication and team work. Effective communication is fundamental to interpersonal, peer, nurse–patient and interprofessional as well as operational function in the health-care context (Morton 2012). The Developing Leader Programme was designed to promote personal and professional growth beginning at entry-level registered nurses and registered nurses at the next level (clinical nurses) to enable them to effectively contribute to clinical leadership in their respective units. The Programme focuses heavily on content, interactions and extension activities that facilitate the development of skills that support self-reflection, good communication and teamwork (Paterson et al. 2010). ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1086–1093
The Developing Leader Programme The Nursing Practice Development Unit at Princess Alexandra Hospital in Brisbane, Australia offers the Developing Leader Programme to registered nurses and clinical nurses. This programme, as described in Paterson et al. (2010), was formulated on the premise that excellence in clinical leadership, contributed to by all nurses, fosters positive working environments that are conducive to excellent outcomes for both patients and staff. Individual nurses may express their interest in participating in the Developing Leader Programme via an online registration site, or they may be nominated by their clinical educator or nurse unit manager. In either case, enrolment in the programme proceeds only with the support of the nurse’s unit manager and/or clinical educator.
Workshops The programme consists of three 1-day workshops scheduled approximately 6 weeks apart. Aspects of Gardner’s Theory of Multiple Intelligences (Gardner 1993), specifically intrapersonal intelligence, informs workshop one and interpersonal intelligence (e.g. selfawareness and reflection needed for effective teams) informs workshop 2. These attributes are consistent with transformational leadership. Transformational leadership has been associated with cultures of trust, collaboration, confidence, shared governance and job satisfaction for nurses (Casida & Parker 2011). It is a major feature of Magnet organisations (American Nurses Credentialing Centre 2008) and, as such, is a major focus for Princess Alexandra Hospital. The content of the third and final workshop includes quality and nurse sensitive indicators, supporting local change, human resource issues, performance appraisal and development and managing clinical incidents (Paterson et al. 2010). For the purposes of the programme, these managerial content areas have been collectively referred to as professional leadership.
Self-directed activities Further to the workshops, participants engage in activities designed to promote utilisation and reflection. Submission of these activities is a requirement for course completion. Strategies to improve participant engagement in the activities have included the introduction of tutorial type sessions in the workshops, which provide opportunity to share 1087
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understanding of the material and individual insights and experiences. At the commencement of each tutorial, participants are reminded of, and agree to the need for confidentiality regarding the sometimes sensitive nature of these discussions. According to the formative evaluations, these tutorial sessions are valuable for the participants. The self-directed activities in which the participants engage as part of the Developing Leader Programme include tasks such as: ● ● ●
● ●
Exploring the relationship between leadership, staff satisfaction and quality patient care in their area; reflecting on their leadership attributes in terms of their strengths and opportunities for improvement; reporting their experiences regarding the effectiveness of specific communication techniques (e.g. assertiveness or conflict management) by describing a situation in which they were involved; observing a clinician providing feedback to a learner; identifying changes they have made to their behaviour through their insights from the program.
Method Evaluation of the Developing Leader Programme was undertaken by a longitudinal paper-based survey, as well as descriptive accounts submitted by participants in response to self-directed activities. The survey involved participants completing the hard copy Leadership Capability Instrument on three occasions: at the commencement of the programme in workshop one, approximately 12 weeks later in workshop three and then approximately 6 months after completion of the programme, when the survey was distributed through the hospital internal mail system. Each participant developed their own respondent ID, not known to the researchers, so individual progression could be tracked.
The participants The Developing Leader Programme was delivered to five cohorts throughout 2011, with a total of 124 registered and clinical nurses commencing. Sixty-six participants attended all three workshops and successfully engaged in the related activities. Participants nursed in a variety of specialties and contexts (e.g. surgical, medical, rehabilitation, oncology and mental health units). The purpose and methodology of the evaluation was explained to the participants at each of the 1088
first workshops. All participants at the first workshops were invited to voluntarily complete the instrument, and 15 minutes of workshop time was allocated to undertake this. A closed box was used to collect both used and unused instruments from the participants. The same process was repeated at the final workshop (workshop three). Only participants who had attended all three workshops and provided evidence of successful engagement in the self-directed activities were sent the third and final survey, including an addressed return envelope approximately 6 months after workshop three. Thirty-eight participants completed at least two of the surveys. In an effort to improve response rates, a reminder letter was sent to participants 3 weeks after the final survey was sent. The voluntary basis of participation in the evaluation was clearly explained each time the instrument was administered.
The instrument The Leadership Capability Instrument was developed from pre-existing tools. Scott et al. (2008) identified personal, interpersonal and cognitive capabilities in their Academic Leadership Capabilities for Australian Higher Education, which aligned well with the intrapersonal, interpersonal and professional aspects of the Developing Leader Programme. Seven capabilities were extracted to use under intrapersonal and interpersonal leadership, and six indicators under professional leadership, as indicated in Table 1. Although anonymous, some demographic details were collected on the tool, specifically years in nursing, years in the facility and highest qualification. Carless et al. (2000) developed a Global Transformational Leadership Scale as a short measure of transformational leadership based on recognised transformational leadership behaviours. The seven resulting items were used with permission in the Leadership Capability Instrument, as listed in Table 2. Collectively, the 27 items were used as the basis of The Leadership Capability Instrument to measure participants’ perception of their leadership capability. Participants rated themselves on a Likert scale against each of the items, with one being very poor and five being excellent.
Data analysis The data was analysed using STATA 11 (Statacorp, Texas, TX, USA) a PC-based software statistical package. Descriptive statistics were used to examine survey respondents’ characteristics. Survey data was checked ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1086–1093
Impact of a leadership development programme
Table 1 Indicators of intrapersonal, interpersonal and professional leadership Indicator Intrapersonal Leadership (Cronbach’s a = 0.82)
Interpersonal Leadership (Cronbach’s a = 0.86)
Professional Leadership (Cronbach’s a = 0.87)
1. Admitting to and learning from errors 2. Understanding your personal strengths and limitations 3. Persevering when things are not working out as anticipated 4. Wanting to achieve the best possible outcome 5. Bouncing back from adversity 6. Remaining calm under pressure or when things take an unexpected turn 7. Keeping things in perspective 8. Influencing people’s behaviour and decisions in effective ways 9. Empathising and working productively with people from a wide range of backgrounds 10. Motivating others to achieve positive outcomes 11. Giving constructive feedback to team members 12. Working constructively with people who are ‘resistors’ 13. Being transparent and honest in dealings with others 14. Developing and using networks of colleagues to solve workplace problems 15. Seeing the best way to respond to a perplexing situation 16. Thinking creatively and laterally 17. Seeing and acting on opportunities for improvement 18. Taking appropriate action to address a problem 19. Identifying from a mass of information the core issue or opportunity 20. Recognising how seemingly unconnected activities are linked
Items 1–20 extracted from the Learning and Teaching Leaders Survey Instrument (Scott et al. 2008).
Table 2 Indicators of transformational leadership
for missing and out of range data values. Distributions of subscale scores were examined for normality through means and standard deviations. Using the survey mean score as the dependent variable, linear regression was used to determine differences between workshop scores. Adjusting for multiple testing using Bonferroni correction still resulted in significant differences. Levels at a = 0.05 level were considered significant. Reliability of the scales was assessed using Cronbach’s alpha with an internal consistency of 0.7 and above considered good.
Results Respondents At the completion of the first workshop 63.7% (n = 79) of attendees responded. The response rate reduced at the second workshop to 42% (n = 28) of the 66 participants who attended all three workshops and increased marginally 6 months afterwards to 46.5% (n = 31). The characteristics of the sample who completed surveys at the first and final workshop, and again 6 months following completion were representative of the registered nurse population of the hospital, that is, the majority of nurses had completed their bachelor degree, with smaller numbers (approximately one-third) having completed a postgraduate qualification (Table 3). Less than 20% of the staff completing the survey at each time-period had not completed either a Bachelor degree or postgraduate qualification. Differences in years of nursing, number of years worked in the facility and educational qualifications were not significantly different
Table 3 Characteristics of sample completing surveys
Indicator Transformational Leadership (Cronbach’s = 0.90)
21. Communicating a clear and positive vision of the future 22. Treating staff as individuals, supporting and encouraging their development 23. Giving encouragement and recognition of staff 24. Fostering trust, involvement and co-operation among team members 25. Encouraging new ways of thinking about problems and questioning assumptions 26. Being clear about your values and practising what you preach 27. Instilling pride and respect in others
Items 21–27 based on the Global Transformational Leadership Scale (Carless et al. 2000). ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1086–1093
First workshop, n = 79 Years in facility Median (IQR) Mean (SD) Years in nursing Median (IQR) Mean (SD) Nursing qualification Hospital certificate, n (%) Diploma, n (%) Bachelor, n (%) Postgraduate, n (%)
5 (3–7.5) 6.3 (5.0)
Final workshop, n = 28
6 months after, n = 31
5 (3–7) 5.1 (3.4)
6 (3.5–10.5) 7.8 (7.2)
10.5 (5–20) 13.3 (9.7)
8.25 (4–20) 12.5 (9.7)
11 (5.5–19.5) 14.1 (10.3)
4 (5)
2 (7)
4 (13)
8 (10) 44 (56) 21 (27)
4 (14) 13 (46) 9 (32)
3 (9) 15 (47) 10 (31)
IQR, Interquartile range; SD, standard deviation.
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for the respondents at each stage suggesting homogeneity between the responding participants at first and final workshop, and 6 months following completion of the course.
Survey findings Respondents at the commencement of the course rated their capability as between three and four, indicating it was in the vicinity of satisfactory to good. These mean scores consistently increased over the duration of the course; 6 months after completion respondents indicated their leadership capability as between good to excellent for all the elements of leadership identified (Table 4). There was a statistically significant incremental increase in nurses’ perceived leadership capability following the second workshop and again 6 months after completion of the course. For three of the leadership elements there were statistically significant incremental changes after the second workshop and again 6 months after completion of the course: these were personal, interpersonal and transformational (P < 0.001; Table 5). Only professional leadership did not increase significantly following the second workshop; however, this scale did increase overall from the first workshop to final survey completion 6 months afterwards. These systematic progressive improvements suggest that the composite and arrangements of programme activities contribute to continuous development of nurses’ leadership ability. Overall, the findings support that participants perceive that their leadership capabilities are improved by completing the programme.
Descriptive account of activities The descriptive accounts were reviewed to better understand what participants had gained. The responses were organised around the learning objec-
Table 4 Mean scores (SD) for each survey
Intrapersonal Interpersonal Professional Transformational Total
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First workshop, n = 79
Final workshop, n = 28
6 months after, n = 31
3.75 3.46 3.53 3.72 3.62
4.14 3.95 3.79 4.22 4.03
4.20 4.05 4.05 4.30 4.16
(0.44) (0.50) (0.80) (0.53) (0.46)
(0.34) (0.40) (0.43) (0.35) (0.32)
(0.38) (0.41) (0.47) (0.48) (0.39)
Table 5 Comparison of mean scores using linear regression Coefficient
95% CI
Comparison of total mean scores First to second survey 0.42 0.23–0.60 First to final survey 0.54 0.36–0.71 Comparison of intrapersonal leadership mean scores First to second survey 0.39 0.21–0.57 First to final survey 0.45 0.27–0.62 Comparison of interpersonal leadership mean scores First to second survey 0.50 0.30–0.70 First to final survey 0.59 0.40–0.79 Comparison of professional leadership mean scores First to second survey 0.26 –0.04–0.55 First to final survey 0.53 0.24–0.81 Comparison of transformational leadership mean scores First to second survey 0.50 0.29–0.72 First to final survey 0.58 0.38–0.79
P-value
< 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 0.08 < 0.001 < 0.001 < 0.001
CI, confidence interval.
tives for each workshop, namely awareness of their own attitudes, their interactions with others, and exploring how to make a difference. Participant responses for the activities supported the effectiveness of the Developing Leader Programme. Many participants made statements and reflections about increased self-awareness and identified specific skills they were improving, such as ‘I’ve changed the way I feel about my work environment’ and ‘I think I have been encouraged to improve my attitude, behaviour and appreciate humour. . . (to assist) the positive work environment’. Of particular interest are participants’ reports of their changed behaviour during and immediately following the leadership programme. How participants apply and demonstrate their learning is an important indicator that learning has occurred; performing in practice is important in demonstrating competence (Rethans et al. 2002). Reported changes by participants (derived from their reported activities) included the following: Awareness of attitudes: ‘Now I attempt to resolve problems or conflict at the point of contact or escalate the issue when I cannot resolve it’. (ID 22) ‘I need to not be affected by others’ negative attitudes. I try to put on a positive front and not be drawn into the negativity and whingeing’. (ID 26) Interactions with others: ‘I’m more aware of when a staff member is overwhelmed and attempt to support them’. (ID 7) ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1086–1093
Impact of a leadership development programme
‘When the department becomes busy, I tend to fall back into authoritarian mode. . . [and] tend to show my frustration (statement made in relation to opportunities for improvement)’. (ID 13) ‘. . .I took the staff member to a quiet area to discuss the incident. Previously I would have ignored the incident. . . I maintained a friendly approach and was clear regarding the incident and the ramifications of the staff member’s actions’. (ID 4) Exploring how to make a difference: ‘When I make requests for staff to perform an activity I follow up to make sure it is completed’. (ID 22) ‘I need to work on managing difficult behaviours [that] impact on the work environment and decay the team’s well-being. . . ’. (ID 17) These statements indicate that participants were seeking to modify their behaviour based on the insights gained by completing the programme. For example, participants had increased their ability to appropriately respond to inappropriate interactions and improve their management of work situations.
Discussion The evaluation of this programme based on the completion of 79 surveys from participants at workshop one, 28 surveys from the final workshop, and 31 surveys returned 6 months after completion of the programme identifies incremental improvement in participants’ perceived leadership capability. The mean scores for each group of capabilities (intrapersonal, interpersonal, professional and transformational) significantly improved between commencement of the programme and 6 months after completion. Of particular significance in this evaluation is not just that participants rated improved capability of leadership elements such as respect, trust, teamwork and effective communication, but rather that the descriptive accounts provided insights into the specific learning of participants, namely, how they professionally challenged behaviours, sought clarification and addressed incidents that they had previously ignored, all of which have a positive impact on patient wellbeing (Squires et al. 2010). Effective clinical leadership at the point of care is responsive to the myriad of contextual factors that ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1086–1093
combine ‘at the bedside’ (Bender et al. 2012). The statistically significant survey ratings and the positive descriptive accounts indicating changed behaviours of the participants suggest that the programme is successful in assisting participants to negotiate complex care issues. Participants identified through the surveys, and their accounts of the activities, that they were more readily able to draw on persuasive techniques and collaborative behaviours rather than rely on structural power to bring about desired changes in patient care delivery. Through encouraging dialogue between the participants and continuing opportunities to share thoughts and reflections the participants were able to provide clarity and coherence around how they can continue to build their leadership capacity.
Limitations There are several limitations that apply to the evaluation of this programme. Using self-report alone to rate leadership capability relies on the accuracy of participant insight, and so cannot be considered an entirely objective measure. In addition, learning occurs through everyday interactions so the lack of a control group means that learning that occurs ordinarily could not be factored into the results. The relatively small total number of programme participants for the time period limits the generalisability of the results. This is compounded by the difficulties in sustaining response rates for longitudinal surveys. Furthermore, those who completed the survey were possibly the most enthusiastic about the programme and learned the most, which may have skewed the results.
Conclusion The need for leadership at all levels of nursing is overwhelmingly evident. Effective leadership has been associated with improved workplace culture, staff satisfaction and, most importantly, improved patient outcomes. This evaluation has revealed that the Developing Leader Programme has a positive impact upon participants’ self-perceived leadership capability. Overall, these results suggest that the programme contributes to nurses’ ability to demonstrate clinical leadership. The capacity to have an impact on clinical leadership is essential because it has been demonstrated that positive clinical leadership affects staff satisfaction and patient care. 1091
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Implications for nursing management The opportunity for further progression of the Developing Leader Programme lies in the design and implementation of an evaluation process to elicit feedback from participants’ line managers regarding their perceptions of participants’ leadership capability. This would serve as a means of confirming (or refuting) self-perceptions of participants. Participants have indicated the value of this course in guiding attitudes and behaviours. Nurse managers should therefore encourage staff to attend such programmes but, more importantly, foster and support staff to draw on the learning at pertinent moments in team interactions. Through recognising and appraising the learning of the participants the programme can significantly contribute to staff demonstrating positive clinical leadership (Henderson et al. 2014). In the time since the longitudinal evaluation was undertaken, a small number of allied health workers at equivalent stages in their career development have also completed the Developing Leader Programme so that some cohorts included two or three different health professional groups. The interaction, networking and shared learning among the professional groups was a positive outcome of this development. A key challenge for nursing educators in Australia is to create leadership and management programmes that meet both the imperatives of the health service context of practice as well as the requirements of the education systems and accreditation bodies (Dignam et al. 2011). It is anticipated that this might be achieved for the Developing Leader Programme by seeking formal recognition of, and articulation with university programmes.
Acknowledgement The authors thank the Nursing Practice Development Unit for their kind support to conduct this evaluation. No external funds were received to conduct this study.
Source of funding The authors did not receive any funding for this paper.
Ethics approval An application for Expedited Ethical Review of the planned evaluation process was submitted to the Prin-
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cess Alexandra Hospital Human Research Ethics Committee before commencing the evaluation. Approval to undertake the evaluation was granted. Survey completion was voluntary. All survey responses were anonymous as there were no questions asked that could identify staff.
References American Nurses Credentialing Centre. (2008) The Manet Recognition Program: Recognising Excellence in Nursing Service, Application Manual 2008. American Nurses Credentialing Centre, Silver Springs, MD. Bender M., Connelly C. & Brown C. (2012) Interdisciplinary collaboration: the role of the nurse leader. Journal of Nursing Management 21, 165–174. Carless S., Wearing A. & Mann L. (2000) A short measure of transformational leadership. Journal of Business and Psychology 14 (3), 389–405. Casida J. & Parker J. (2011) Staff nurse perceptions of nurse manager leadership styles and outcomes. Journal of Nursing Management 19, 478–486. Dignam D., Duffield C., Stasa H., Gray J., Jackson D. & Daly J. (2011) Management and leadership in nursing: an Australian perspective. Journal of Nursing Management 20, 65–71. Dyess S. & Parker C. (2012) Transition support for the newly licensed nurse: a program that made a difference. Journal of Nursing Management 20, 615–623. Gardner H. (1993) Multiple Intelligences: The Theory in Practice. Basic Books, New York, NY. Henderson A., Schoonbeek S., Ossenberg C., Burmeister L. & Gneilding J. (2014) The impact of engaging middle management in practice interventions on staff perceptions of support and learning culture: a quasi-experimental design. Journal of Nursing Management doi:10.1111/jonm.12090 [Epub ahead of print]. Martin J., McCormack B., Fitzsimons D. & Sprig R. (2012) Evaluation of a clinical leadership programme for nurse leaders. Journal of Nursing Management 20, 72–80. Morton J. (2012) Management and leadership at the bedside. Journal of Nursing Management 20, 579–581. Nursing & Midwifery Board of Australia. (2006). National Competency Standards for the Registered Nurse. Available at: http://www.nursingmidwiferyboard.gov.au/Codes-GuidelinesStatements/Codes-Guidelines.aspx#competencystandards, accessed 10 November 2013. Paterson K., Henderson A. & Trivella A. (2010) Educating for leadership: a programme designed to build a responsive health care culture. Journal of Nursing Management 18, 78–83. Patrick A., Spence Laschinger H., Wong C. & Finegan J. (2011) Developing and testing a new measure of staff nurse clinical leadership: the clinical leadership survey. Journal of Nursing Management 19, 449–460. Perry L. (2012) What do nurse leaders do? Journal of Advanced Nursing 68 (2), 247. Rethans J., Norcini J., Bar on-Maldonado M. et al. (2002) The relationship between competence and performance: implications for assessing practice performance. Medical Education 36, 901–909. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1086–1093
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Scott G., Coates H. & Anderson M. (2008) Learning Leadership in Times of Change: Academic Leadership Capabilities for Australian Higher Education. University of Western Sydney and Australian Council for Education Research Sydney. Available at: http://research.acer.edu.au/cgi/viewcontent.cgi? article=1001&context=higher_education, accessed 10 November 2009.
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Squires M., Tourangeau A., Spence Laschinger H. & Doran D. (2010) The link between safety and outcomes in hospitals. Journal of Nursing Management 18, 914–925. Swearingen S. (2009) A journey to leadership: designing a nursing leadership development program. Journal of Continuing Education in Nursing 40 (4), 107–112.
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The impact of a leadership development programme on nurses’ self-perceived leadership capability KARYN PATERSON B H S c BURMEISTER R N , P h D 3
(Nurs) MEd
1
, AMANDA HENDERSON
RN, RM, PhD
2
and ELIZABETH
1
Nurse Educator, 2Nursing Director (Education) and 3Nurse Researcher, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Australia
Correspondence Amanda Henderson Nursing Practice Development Unit Princess Alexandra Hospital Ipswich Road Woolloongabba 4102 Queensland Australia E-mail: Amanda_Henderson@ health.qld.gov.au
PATERSON K., HENDERSON A. & BURMEISTER E.
(2015) Journal of Nursing Management 23, 1086–1093. The impact of a leadership development programme on nurses’ selfperceived leadership capability Aim This paper reports on the outcomes of a locally designed educational programme to support leadership capability of junior registered nurses. Background The Developing Leader Programme is an in-house programme delivered in three face-to-face workshops, comprising self-directed reflective and application activities. Method Surveys were used to evaluate self-perceived leadership capability over a 9month period. The survey comprised a Leadership Capability Instrument adapted from two existing tools. Participants completed surveys at the commencement of the programme, after the third and final workshop and approximately 6 months afterwards. In addition, examples of descriptive accounts of programme activities submitted by individual participants were included to enrich data. Results Of 124 participants, 79 completed surveys at the first workshop, 28 at the final workshop and 31 were returned 6 months after completion of the programme. Mean scores for each area of leadership capability significantly improved throughout the duration of the programme (P < 0.001). Participants also indicated a willingness to enact leadership behaviours through reported activities. Conclusions Survey responses indicated that participants perceived improved leadership capability after completing the Developing Leader Programme. Implications for nursing management Early educational intervention to facilitate the development of leadership skills as well as clinical skills in junior registered nurses can assist with how they interact with the team. Participation of junior registered nurses in a locally designed leadership programme can assist them to develop leadership behaviours for everyday practice. Keywords: evaluation, nursing leadership, nursing practice, practice leadership
Accepted for publication: 30 June 2014
Introduction Acute health care environments are characterised by a frenetic pace, high patient acuity, a demand for quality and safety, and increasingly limited lengths of stay (Dyess & Parker 2012). The literature continues to support the need for effective leadership in such environments, 1086
because leadership has been shown to be important in establishing and maintaining team relationships that foster high-quality and safe nursing environments conducive to nurses voicing concerns and asking for help (Squires et al. 2010), attracting and retaining staff, and improving staff satisfaction (Swearingen 2009, Dignam et al. 2011), providing patient-centred, evidence based DOI: 10.1111/jonm.12257 ª 2014 John Wiley & Sons Ltd
Impact of a leadership development programme
and outcome oriented care (Martin et al. 2012) and managing change (Perry 2012). The concept of clinical leadership at the point of care is an area of increasing interest in health-care environments (Patrick et al. 2011). Leadership at all levels of nursing, including informal leadership practised by clinicians is important in this regard (Swearingen 2009). Clinical leadership may be defined as nurse behaviours that provide direction and support to patients and the health-care team in the delivery of care (Patrick et al. 2011). The primary focus of clinical leadership is the patient rather than the organisation, and persuasion and collaboration rather than structural power are used to plan and enact change (Bender et al. 2012). In championing this concept of leadership at all levels of nursing, Morton (2012) espouses the significance of the ‘inner leader’ of the bedside nurse who models and empowers change, and who brings knowledge and understanding to individual practice and team collaboration. In Australia, there is an explicit requirement of the national competency standards for registered nurses that all registered nurses take a leadership role in the coordination of nursing and health care to facilitate optimal health outcomes (Nursing & Midwifery Board of Australia 2006).
Origin of the programme Students and nurses beginning practice are generally well supported to acquire and practise clinical skills; however, fewer opportunities are provided for them to gain and practise leadership skills. Many of the available leadership programmes are designed to prepare nurses for leadership roles once they are formally appointed into leadership positions, and are aimed at the nurse unit manager level or higher (Paterson et al. 2010). Clinical leadership refers to nurses drawing on their clinical expertise to make decisions and initiate change to improve patient wellbeing. Such leadership is heavily dependent on successful communication and team work. Effective communication is fundamental to interpersonal, peer, nurse–patient and interprofessional as well as operational function in the health-care context (Morton 2012). The Developing Leader Programme was designed to promote personal and professional growth beginning at entry-level registered nurses and registered nurses at the next level (clinical nurses) to enable them to effectively contribute to clinical leadership in their respective units. The Programme focuses heavily on content, interactions and extension activities that facilitate the development of skills that support self-reflection, good communication and teamwork (Paterson et al. 2010). ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1086–1093
The Developing Leader Programme The Nursing Practice Development Unit at Princess Alexandra Hospital in Brisbane, Australia offers the Developing Leader Programme to registered nurses and clinical nurses. This programme, as described in Paterson et al. (2010), was formulated on the premise that excellence in clinical leadership, contributed to by all nurses, fosters positive working environments that are conducive to excellent outcomes for both patients and staff. Individual nurses may express their interest in participating in the Developing Leader Programme via an online registration site, or they may be nominated by their clinical educator or nurse unit manager. In either case, enrolment in the programme proceeds only with the support of the nurse’s unit manager and/or clinical educator.
Workshops The programme consists of three 1-day workshops scheduled approximately 6 weeks apart. Aspects of Gardner’s Theory of Multiple Intelligences (Gardner 1993), specifically intrapersonal intelligence, informs workshop one and interpersonal intelligence (e.g. selfawareness and reflection needed for effective teams) informs workshop 2. These attributes are consistent with transformational leadership. Transformational leadership has been associated with cultures of trust, collaboration, confidence, shared governance and job satisfaction for nurses (Casida & Parker 2011). It is a major feature of Magnet organisations (American Nurses Credentialing Centre 2008) and, as such, is a major focus for Princess Alexandra Hospital. The content of the third and final workshop includes quality and nurse sensitive indicators, supporting local change, human resource issues, performance appraisal and development and managing clinical incidents (Paterson et al. 2010). For the purposes of the programme, these managerial content areas have been collectively referred to as professional leadership.
Self-directed activities Further to the workshops, participants engage in activities designed to promote utilisation and reflection. Submission of these activities is a requirement for course completion. Strategies to improve participant engagement in the activities have included the introduction of tutorial type sessions in the workshops, which provide opportunity to share 1087
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understanding of the material and individual insights and experiences. At the commencement of each tutorial, participants are reminded of, and agree to the need for confidentiality regarding the sometimes sensitive nature of these discussions. According to the formative evaluations, these tutorial sessions are valuable for the participants. The self-directed activities in which the participants engage as part of the Developing Leader Programme include tasks such as: ● ● ●
● ●
Exploring the relationship between leadership, staff satisfaction and quality patient care in their area; reflecting on their leadership attributes in terms of their strengths and opportunities for improvement; reporting their experiences regarding the effectiveness of specific communication techniques (e.g. assertiveness or conflict management) by describing a situation in which they were involved; observing a clinician providing feedback to a learner; identifying changes they have made to their behaviour through their insights from the program.
Method Evaluation of the Developing Leader Programme was undertaken by a longitudinal paper-based survey, as well as descriptive accounts submitted by participants in response to self-directed activities. The survey involved participants completing the hard copy Leadership Capability Instrument on three occasions: at the commencement of the programme in workshop one, approximately 12 weeks later in workshop three and then approximately 6 months after completion of the programme, when the survey was distributed through the hospital internal mail system. Each participant developed their own respondent ID, not known to the researchers, so individual progression could be tracked.
The participants The Developing Leader Programme was delivered to five cohorts throughout 2011, with a total of 124 registered and clinical nurses commencing. Sixty-six participants attended all three workshops and successfully engaged in the related activities. Participants nursed in a variety of specialties and contexts (e.g. surgical, medical, rehabilitation, oncology and mental health units). The purpose and methodology of the evaluation was explained to the participants at each of the 1088
first workshops. All participants at the first workshops were invited to voluntarily complete the instrument, and 15 minutes of workshop time was allocated to undertake this. A closed box was used to collect both used and unused instruments from the participants. The same process was repeated at the final workshop (workshop three). Only participants who had attended all three workshops and provided evidence of successful engagement in the self-directed activities were sent the third and final survey, including an addressed return envelope approximately 6 months after workshop three. Thirty-eight participants completed at least two of the surveys. In an effort to improve response rates, a reminder letter was sent to participants 3 weeks after the final survey was sent. The voluntary basis of participation in the evaluation was clearly explained each time the instrument was administered.
The instrument The Leadership Capability Instrument was developed from pre-existing tools. Scott et al. (2008) identified personal, interpersonal and cognitive capabilities in their Academic Leadership Capabilities for Australian Higher Education, which aligned well with the intrapersonal, interpersonal and professional aspects of the Developing Leader Programme. Seven capabilities were extracted to use under intrapersonal and interpersonal leadership, and six indicators under professional leadership, as indicated in Table 1. Although anonymous, some demographic details were collected on the tool, specifically years in nursing, years in the facility and highest qualification. Carless et al. (2000) developed a Global Transformational Leadership Scale as a short measure of transformational leadership based on recognised transformational leadership behaviours. The seven resulting items were used with permission in the Leadership Capability Instrument, as listed in Table 2. Collectively, the 27 items were used as the basis of The Leadership Capability Instrument to measure participants’ perception of their leadership capability. Participants rated themselves on a Likert scale against each of the items, with one being very poor and five being excellent.
Data analysis The data was analysed using STATA 11 (Statacorp, Texas, TX, USA) a PC-based software statistical package. Descriptive statistics were used to examine survey respondents’ characteristics. Survey data was checked ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1086–1093
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Table 1 Indicators of intrapersonal, interpersonal and professional leadership Indicator Intrapersonal Leadership (Cronbach’s a = 0.82)
Interpersonal Leadership (Cronbach’s a = 0.86)
Professional Leadership (Cronbach’s a = 0.87)
1. Admitting to and learning from errors 2. Understanding your personal strengths and limitations 3. Persevering when things are not working out as anticipated 4. Wanting to achieve the best possible outcome 5. Bouncing back from adversity 6. Remaining calm under pressure or when things take an unexpected turn 7. Keeping things in perspective 8. Influencing people’s behaviour and decisions in effective ways 9. Empathising and working productively with people from a wide range of backgrounds 10. Motivating others to achieve positive outcomes 11. Giving constructive feedback to team members 12. Working constructively with people who are ‘resistors’ 13. Being transparent and honest in dealings with others 14. Developing and using networks of colleagues to solve workplace problems 15. Seeing the best way to respond to a perplexing situation 16. Thinking creatively and laterally 17. Seeing and acting on opportunities for improvement 18. Taking appropriate action to address a problem 19. Identifying from a mass of information the core issue or opportunity 20. Recognising how seemingly unconnected activities are linked
Items 1–20 extracted from the Learning and Teaching Leaders Survey Instrument (Scott et al. 2008).
Table 2 Indicators of transformational leadership
for missing and out of range data values. Distributions of subscale scores were examined for normality through means and standard deviations. Using the survey mean score as the dependent variable, linear regression was used to determine differences between workshop scores. Adjusting for multiple testing using Bonferroni correction still resulted in significant differences. Levels at a = 0.05 level were considered significant. Reliability of the scales was assessed using Cronbach’s alpha with an internal consistency of 0.7 and above considered good.
Results Respondents At the completion of the first workshop 63.7% (n = 79) of attendees responded. The response rate reduced at the second workshop to 42% (n = 28) of the 66 participants who attended all three workshops and increased marginally 6 months afterwards to 46.5% (n = 31). The characteristics of the sample who completed surveys at the first and final workshop, and again 6 months following completion were representative of the registered nurse population of the hospital, that is, the majority of nurses had completed their bachelor degree, with smaller numbers (approximately one-third) having completed a postgraduate qualification (Table 3). Less than 20% of the staff completing the survey at each time-period had not completed either a Bachelor degree or postgraduate qualification. Differences in years of nursing, number of years worked in the facility and educational qualifications were not significantly different
Table 3 Characteristics of sample completing surveys
Indicator Transformational Leadership (Cronbach’s = 0.90)
21. Communicating a clear and positive vision of the future 22. Treating staff as individuals, supporting and encouraging their development 23. Giving encouragement and recognition of staff 24. Fostering trust, involvement and co-operation among team members 25. Encouraging new ways of thinking about problems and questioning assumptions 26. Being clear about your values and practising what you preach 27. Instilling pride and respect in others
Items 21–27 based on the Global Transformational Leadership Scale (Carless et al. 2000). ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1086–1093
First workshop, n = 79 Years in facility Median (IQR) Mean (SD) Years in nursing Median (IQR) Mean (SD) Nursing qualification Hospital certificate, n (%) Diploma, n (%) Bachelor, n (%) Postgraduate, n (%)
5 (3–7.5) 6.3 (5.0)
Final workshop, n = 28
6 months after, n = 31
5 (3–7) 5.1 (3.4)
6 (3.5–10.5) 7.8 (7.2)
10.5 (5–20) 13.3 (9.7)
8.25 (4–20) 12.5 (9.7)
11 (5.5–19.5) 14.1 (10.3)
4 (5)
2 (7)
4 (13)
8 (10) 44 (56) 21 (27)
4 (14) 13 (46) 9 (32)
3 (9) 15 (47) 10 (31)
IQR, Interquartile range; SD, standard deviation.
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for the respondents at each stage suggesting homogeneity between the responding participants at first and final workshop, and 6 months following completion of the course.
Survey findings Respondents at the commencement of the course rated their capability as between three and four, indicating it was in the vicinity of satisfactory to good. These mean scores consistently increased over the duration of the course; 6 months after completion respondents indicated their leadership capability as between good to excellent for all the elements of leadership identified (Table 4). There was a statistically significant incremental increase in nurses’ perceived leadership capability following the second workshop and again 6 months after completion of the course. For three of the leadership elements there were statistically significant incremental changes after the second workshop and again 6 months after completion of the course: these were personal, interpersonal and transformational (P < 0.001; Table 5). Only professional leadership did not increase significantly following the second workshop; however, this scale did increase overall from the first workshop to final survey completion 6 months afterwards. These systematic progressive improvements suggest that the composite and arrangements of programme activities contribute to continuous development of nurses’ leadership ability. Overall, the findings support that participants perceive that their leadership capabilities are improved by completing the programme.
Descriptive account of activities The descriptive accounts were reviewed to better understand what participants had gained. The responses were organised around the learning objec-
Table 4 Mean scores (SD) for each survey
Intrapersonal Interpersonal Professional Transformational Total
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First workshop, n = 79
Final workshop, n = 28
6 months after, n = 31
3.75 3.46 3.53 3.72 3.62
4.14 3.95 3.79 4.22 4.03
4.20 4.05 4.05 4.30 4.16
(0.44) (0.50) (0.80) (0.53) (0.46)
(0.34) (0.40) (0.43) (0.35) (0.32)
(0.38) (0.41) (0.47) (0.48) (0.39)
Table 5 Comparison of mean scores using linear regression Coefficient
95% CI
Comparison of total mean scores First to second survey 0.42 0.23–0.60 First to final survey 0.54 0.36–0.71 Comparison of intrapersonal leadership mean scores First to second survey 0.39 0.21–0.57 First to final survey 0.45 0.27–0.62 Comparison of interpersonal leadership mean scores First to second survey 0.50 0.30–0.70 First to final survey 0.59 0.40–0.79 Comparison of professional leadership mean scores First to second survey 0.26 –0.04–0.55 First to final survey 0.53 0.24–0.81 Comparison of transformational leadership mean scores First to second survey 0.50 0.29–0.72 First to final survey 0.58 0.38–0.79
P-value
< 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 0.08 < 0.001 < 0.001 < 0.001
CI, confidence interval.
tives for each workshop, namely awareness of their own attitudes, their interactions with others, and exploring how to make a difference. Participant responses for the activities supported the effectiveness of the Developing Leader Programme. Many participants made statements and reflections about increased self-awareness and identified specific skills they were improving, such as ‘I’ve changed the way I feel about my work environment’ and ‘I think I have been encouraged to improve my attitude, behaviour and appreciate humour. . . (to assist) the positive work environment’. Of particular interest are participants’ reports of their changed behaviour during and immediately following the leadership programme. How participants apply and demonstrate their learning is an important indicator that learning has occurred; performing in practice is important in demonstrating competence (Rethans et al. 2002). Reported changes by participants (derived from their reported activities) included the following: Awareness of attitudes: ‘Now I attempt to resolve problems or conflict at the point of contact or escalate the issue when I cannot resolve it’. (ID 22) ‘I need to not be affected by others’ negative attitudes. I try to put on a positive front and not be drawn into the negativity and whingeing’. (ID 26) Interactions with others: ‘I’m more aware of when a staff member is overwhelmed and attempt to support them’. (ID 7) ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1086–1093
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‘When the department becomes busy, I tend to fall back into authoritarian mode. . . [and] tend to show my frustration (statement made in relation to opportunities for improvement)’. (ID 13) ‘. . .I took the staff member to a quiet area to discuss the incident. Previously I would have ignored the incident. . . I maintained a friendly approach and was clear regarding the incident and the ramifications of the staff member’s actions’. (ID 4) Exploring how to make a difference: ‘When I make requests for staff to perform an activity I follow up to make sure it is completed’. (ID 22) ‘I need to work on managing difficult behaviours [that] impact on the work environment and decay the team’s well-being. . . ’. (ID 17) These statements indicate that participants were seeking to modify their behaviour based on the insights gained by completing the programme. For example, participants had increased their ability to appropriately respond to inappropriate interactions and improve their management of work situations.
Discussion The evaluation of this programme based on the completion of 79 surveys from participants at workshop one, 28 surveys from the final workshop, and 31 surveys returned 6 months after completion of the programme identifies incremental improvement in participants’ perceived leadership capability. The mean scores for each group of capabilities (intrapersonal, interpersonal, professional and transformational) significantly improved between commencement of the programme and 6 months after completion. Of particular significance in this evaluation is not just that participants rated improved capability of leadership elements such as respect, trust, teamwork and effective communication, but rather that the descriptive accounts provided insights into the specific learning of participants, namely, how they professionally challenged behaviours, sought clarification and addressed incidents that they had previously ignored, all of which have a positive impact on patient wellbeing (Squires et al. 2010). Effective clinical leadership at the point of care is responsive to the myriad of contextual factors that ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 1086–1093
combine ‘at the bedside’ (Bender et al. 2012). The statistically significant survey ratings and the positive descriptive accounts indicating changed behaviours of the participants suggest that the programme is successful in assisting participants to negotiate complex care issues. Participants identified through the surveys, and their accounts of the activities, that they were more readily able to draw on persuasive techniques and collaborative behaviours rather than rely on structural power to bring about desired changes in patient care delivery. Through encouraging dialogue between the participants and continuing opportunities to share thoughts and reflections the participants were able to provide clarity and coherence around how they can continue to build their leadership capacity.
Limitations There are several limitations that apply to the evaluation of this programme. Using self-report alone to rate leadership capability relies on the accuracy of participant insight, and so cannot be considered an entirely objective measure. In addition, learning occurs through everyday interactions so the lack of a control group means that learning that occurs ordinarily could not be factored into the results. The relatively small total number of programme participants for the time period limits the generalisability of the results. This is compounded by the difficulties in sustaining response rates for longitudinal surveys. Furthermore, those who completed the survey were possibly the most enthusiastic about the programme and learned the most, which may have skewed the results.
Conclusion The need for leadership at all levels of nursing is overwhelmingly evident. Effective leadership has been associated with improved workplace culture, staff satisfaction and, most importantly, improved patient outcomes. This evaluation has revealed that the Developing Leader Programme has a positive impact upon participants’ self-perceived leadership capability. Overall, these results suggest that the programme contributes to nurses’ ability to demonstrate clinical leadership. The capacity to have an impact on clinical leadership is essential because it has been demonstrated that positive clinical leadership affects staff satisfaction and patient care. 1091
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Implications for nursing management The opportunity for further progression of the Developing Leader Programme lies in the design and implementation of an evaluation process to elicit feedback from participants’ line managers regarding their perceptions of participants’ leadership capability. This would serve as a means of confirming (or refuting) self-perceptions of participants. Participants have indicated the value of this course in guiding attitudes and behaviours. Nurse managers should therefore encourage staff to attend such programmes but, more importantly, foster and support staff to draw on the learning at pertinent moments in team interactions. Through recognising and appraising the learning of the participants the programme can significantly contribute to staff demonstrating positive clinical leadership (Henderson et al. 2014). In the time since the longitudinal evaluation was undertaken, a small number of allied health workers at equivalent stages in their career development have also completed the Developing Leader Programme so that some cohorts included two or three different health professional groups. The interaction, networking and shared learning among the professional groups was a positive outcome of this development. A key challenge for nursing educators in Australia is to create leadership and management programmes that meet both the imperatives of the health service context of practice as well as the requirements of the education systems and accreditation bodies (Dignam et al. 2011). It is anticipated that this might be achieved for the Developing Leader Programme by seeking formal recognition of, and articulation with university programmes.
Acknowledgement The authors thank the Nursing Practice Development Unit for their kind support to conduct this evaluation. No external funds were received to conduct this study.
Source of funding The authors did not receive any funding for this paper.
Ethics approval An application for Expedited Ethical Review of the planned evaluation process was submitted to the Prin-
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cess Alexandra Hospital Human Research Ethics Committee before commencing the evaluation. Approval to undertake the evaluation was granted. Survey completion was voluntary. All survey responses were anonymous as there were no questions asked that could identify staff.
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