Art & science |
The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
A FRAMEWORK FOR PRE-QUALIFYING NURSES TO BUILD LEADERSHIP SKILLS Karen Buckwell-Nutt and colleagues describe the development of an innovative module to help students become better leaders Correspondence [email protected] Karen Buckwell-Nutt is head of academic department, pre-qualifying nursing Jayne Francis-Shama is a senior lecturer, pre-qualifying nursing Pollyanna Kellett is a senior lecturer, pre-qualifying nursing All at the faculty of society and health, Buckinghamshire New University Date of submission July 1 2014 Date of acceptance August 26 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ nm-author-guidelines
Abstract Nursing students are our future leaders in the healthcare sector. It is proposed that, for students to understand and demonstrate leadership knowledge, skills and attributes effectively, they need to: learn concepts, experience leadership roles, analyse their capabilities and develop these with the support of practitioners. The drive to improve nursing leadership does not come from within academia but from practitioners and other stakeholders, such as patients, the Nursing and Midwifery Council and Health Education England, and this need is reflected in the university curriculum. This article reviews a final-year module on personal development for leadership and management and highlights the
Contemporary leadership in the NHS INEFFECTIVE LEADERSHIP has become the focus of blame for some failings in the NHS (Francis 2013). This has been accentuated by the challenge of delivering consistently high quality patient care in today’s demanding and complex healthcare landscape (Nagel and Andenoro 2012). Leadership style has influenced the development of leadership in nursing for decades. For example, transformational and transactional leadership emerged in the 1990s as the dominant framework (Rogers 2012) following Burn’s (1978) seminal work. This emphasised the individualist role and heroic view of leaders as nurturing, motivated individuals who can encourage innovation and creativity in teams. However, despite the
16 November 2014 | Volume 21 | Number 7
importance of continued practice support in developing leadership skills and confidence. The educational approaches, including lectures, the use of problembased scenarios and enquiry-based learning, are explored and the inclusion of e-learning methods is discussed. Students are made aware that placement expectations are different from those in previous years. Recommendations include strategies to strengthen practice support for students who need to develop leadership skills. Keywords Leadership, pre-registration nurse education, academia, shared leadership, distributed leadership, quality promotion of a transformational leadership style, the rigid hierarchical structure of the NHS has prohibited an effective approach to leadership (Roebuck 2011). This problem has not been overcome, but the model proposed here aids students to challenge more. Nurse leadership is going through unprecedented change, heightened by a view that a shared model of leadership should be integrated into the profession (Fulop and Day 2010, MacPhee et al 2011). Shared, or distributed, leadership is an emerging role that views leadership in terms of collaboration and collective activity that no longer embraces the heroic individual leader. It is this view that is being promoted as the NURSING MANAGEMENT
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Art & science | education In nurse education, recognition of the importance of leadership is not addressed until students are within months of qualifying future leadership model in health care (Block and Manning 2007). The concept of shared leadership is reflected in the current NHS leadership framework (NHS Leadership Academy 2014), which provides a consistent approach to leadership development for all staff in health care irrespective of discipline, role or seniority. The NHS leadership framework, titled the Healthcare Leadership Model, represents the standard for leadership behaviours to which all staff should aspire. Fundamental to the development of the Healthcare Leadership Model is a desire to create a single, overarching framework for all health and care staff, building on best-practice standards for leadership development (NHS Leadership Academy 2014). The shared leadership model is different from the traditional individualistic models of leadership (Turnball James 2011). According to the Healthcare Leadership Model, rather than focus on a set of personal attributes, leaders are to be supported by a network of people engaging in leadership practices throughout the organisation (Elliott and Stead 2008, Gronn 2008, Turnball James 2011). The new shared leadership role is embedded in a culture of collaboration, partnership working and reduced hierarchy, with individuals displaying effective interpersonal skills and an ability to deal with conflict (Crevani et al 2007, Fulop and Day 2010). Leadership in pre-registration nurse education therefore faces immense challenges to develop undergraduate nurses with the ability and drive to promote a shared leadership culture in the profession. The preparation of leaders who will make the types of decisions needed in today’s complex healthcare environment requires innovative approaches to learning (Wilson et al 2010). With the focus on patient outcomes and safety, it is imperative that preceptee nurses enter practice settings with leadership capabilities (Hendricks et al 2010). In nurse education in the UK, recognition of the importance of leadership is not addressed until students are within months of qualifying. This results in undergraduate nurses entering clinical environments unprepared to take on leadership demands. In light of this, there is a call for undergraduate nurse training programmes to 18 November 2014 | Volume 21 | Number 7
implement leadership at each level of the course to embed in students a growing interest in and realistic perspective of the demands of leadership (Hendricks et al 2010).
Pedagogical considerations There are varying components that universities have recognised as essential to the development of leadership awareness and adult learning principles, including communication skills and conflict (Hsiu-Yueh et al 2011). However, a clear Nursing and Midwifery Council (NMC) (2010) directive about the leadership qualities of nurses calls for fundamental elements to be in place. Universities and clinical areas that support undergraduate nursing students must collaborate as each setting can offer students differing perspectives on leadership (Allan 2010). First, universities need to meet the pedagogic needs of students, ensuring that differing learning styles are addressed and innovative teaching is provided. Second, clinical areas need to ensure that students are exposed to examples of high functioning nurse leaders who demonstrate the qualities of a leader. Traditional pedagogy has centred on teacher-dominated perspectives, with the transfer of information to students in a pre-determined manner (Horsfall et al 2012, Tedesco-Schneck 2012). This style of pedagogy, which relies on recall and factual forms of knowledge, has attracted criticism around its inability to reduce the gap between what is taught in classrooms and the realities of clinical practice (Leigh et al 2012). Traditionally the ‘talk and chalk’ lecture method (Young et al 2009) presents to students a passive form of learning that achieves engagement for a minimum amount of time and fails to promote deep learning (Toynton 2005, Machemer and Crawford 2007, Cherney 2008). The constructivist view of learning suggests that a teacher lecturing to a class may not always be the most effective way for adult students to learn (Kapp and Fergason 2002). Contemporary pedagogical theory, therefore, aims to promote leadership development through the incorporation of a unifying theoretical framework that links to nursing practice and research and that provides the basis for decision making with regard to content (MacPhee et al 2011). When considering the complex nature of leadership, an experiential learning approach to encourage students to critically evaluate concepts, think laterally and apply theoretical positions during problem-solving exercises is more productive (Banning 2005). The experiential NURSING MANAGEMENT
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learning approach allows the transition of knowledge into clinical settings. The NMC (2010) has included leadership and team working in its revised standards for pre-registration nursing education. Here the aim, as a generic standard of competence, is for all nurses to qualify with an ability to provide leadership in managing nursing care and to co-ordinate interprofessional care when needed. In support of this, Willis (Willis Commission 2012) documents the significance of leadership in nursing curricula. Importantly, the exposure to skilled, positive leadership role modelling is identified as critical to developing leadership knowledge in undergraduate students (Omoike et al 2011, Willis Commission 2012). The challenges for curriculum development at Buckinghamshire and more generally were clear: to help students understand shared leadership, which has emerged as the future model for the NHS (Block and Manning 2007); and to enable them to incorporate and develop this into their own emergent leadership style. With a need to provide students with important leadership and management skills in a university setting to prepare them for practice as third-year nursing students, and beyond to their preceptorship and future years as registered nurses, the imperative is to bridge the theory-practice gap and bring contemporary leadership issues into the classroom for discussion and analysis in a safe environment. The demands of nurse education are multifaceted and the debate on its effectiveness continues. Meanwhile, there is a requirement for graduate nurses to achieve additional skills relating to leadership (NMC 2010), including an ability to: ■ Act as change agents and provide leadership through high quality systems. ■ Identify priorities, and manage time and resources effectively. ■ Take the lead in co-ordinating, delegating and supervising care safely. ■ Manage risk and remain accountable for the care given. ■ Maintain their personal and professional development. To address these leadership requirements, a module entitled Personal Development for Leadership and Management was developed at Buckinghamshire. Transformational learning The educational framework underpinning the module is transformational learning. The precepts of this approach involve students experiencing a shift of understanding. This shift is not independent NURSING MANAGEMENT
of content, context or discipline, and any activity or resource that presents students with alternative views to their own can be used (Meyer et al 2010). It requires lecturers to create dynamic relationships between themselves, the students and the ‘body of knowledge’ to promote students’ understandings and personal development (Slavich and Zimbardo 2012). The module team used a spiral curriculum approach (Bruner 2009), which posits that students should revisit a concept or skill regularly but that each time the complexity increases and that any new learning relates to old understanding. As this is a final-year module and was aimed at building on students’ knowledge and skills already acquired in the programme, a progressive themed approach was adopted. This is explained as moving students from current understandings towards identification of new knowledge and skills, thereby developing these skills in clinical settings. This approach, in part, addresses the limitations of modular programmes, namely that they are fragmented (Carmen et al 2011). Various activities were designed to accommodate different learning styles (Honey and Mumford 2006). Box 1 Examples of activities and content Learn
Accountability, delegation, leadership theories and styles, conflict management, principles of managing resources, emotional intelligence preceptorship, employability.
Experience
Problem-based scenarios involving, for example, staff allocation, prioritising care, communication, complaint management, presenting innovative practice, clinical management in placement.
Analyse
Strengths, weaknesses, opportunities and threats (SWOT) analysis, Johari windows, leadership framework self-assessment tools, interview critique, problem solving self-assessment.
Develop
Creation and implementation of learning plans, negotiation skills, communication skills, practice leadership and management skills with support of practitioners. November 2014 | Volume 21 | Number 7 19
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Art & science | education Innovative design framework The Learn, Experience, Analyse, Develop (LEAD) framework was created to design the module flow and the presentation of content. See Box 1 for examples of activities and content. The module delivery consisted of seminars, lead lectures, e-learning activities and an employability day. The small group seminars enabled discussions of key themes and exploration of a three-stage field-specific, problem-based clinical leadership scenario. Through the use of problem-based scenario activities, students were encouraged to explore concepts, think creatively and apply solutions during problem-solving exercises (Banning 2005). During lead lectures, new concepts, including theories of leadership and conflict management, were introduced. Students had the opportunity to explore and test the new concepts further during the problem-based seminars and preceptorship. While the traditional teacher-centred lecture method could be criticised for its transmission of information to the passive student, this opportunity for large group teaching is economically justified. By adopting an interactive style in the one-hour lectures, students had the opportunity to be less passive. As well as using a question-and-answer technique, the inclusion of popular culture, for example reference to common activities such as the use of mobile telephones or social media networks, and artefacts from mass media, such as current soap opera storylines or recent news headlines, enabled the lecturer to ‘connect with the adult learner’ (Wright and Sandlin 2009). The virtual learning environment (VLE) was carefully structured to make explicit the prerequisites for classroom-based sessions and suggested additional independent learning activities with which students could chose to engage. The e-learning activities were congruent with the themes addressed each week in the classroom sessions. Sharpe et al (2006) suggest that students need to understand the use of technology in their learning and that educators need to be consistent and transparent in communicating their expectations to students. The expectation that students engage with the VLE materials was made clear at the beginning of the module and reinforced throughout by the seminar lecturer. For the VLE and seminars to be effective, students are required to self-regulate their learning. O’Shea (2003) suggests that nurse educators must help nurses develop the skill of self-regulated 20 November 2014 | Volume 21 | Number 7
learning so they can meet the challenges of constantly changing healthcare environments. Nursing innovations The NMC (2010) requires graduate nurses to act as change agents and provide leadership through good quality systems. To consider innovation and implementation of change in practice, students were guided through an enquiry-based learning (EBL) method (Khan and O’Rourke 2005) to explore important innovative practices appropriate to their fields of nursing; these might include use of the safety thermometer (NHS Quality Observatory 2012), red-tray system (Royal College of Nursing (RCN) 2014) or the Productive Ward initiative (NHS Institute for Innovation and Improvement 2007). Through this process, students seek evidence to support ideas triggered by a topic and take responsibility for analysing and presenting this evidence to peers in their seminar group. NHS Improving Quality (2013) advocates staff empowerment and proposes innovative ways of delivering good quality services. The RCN supports the definition of innovation offered by West and Farr (1990) as ‘the intentional introduction and application within a role, group or organization of ideas, processes, products or procedures, new to the relevant unit of adoption, designed to significantly benefit the individual, the group, the organization or wider society’. The transferable skills required to source, analyse and present evidence are fundamental to developing confidence to challenge and change practice. Increasing awareness Initially, students were required to revisit their understanding of healthcare assistant (HCA), nursing student and registered nurse roles and responsibilities, and the concept of accountability and delegation. Through the use of self-evaluative tools, strengths, weaknesses, opportunities and threats (SWOT) analysis and Johari windows (Self Awareness LLP 2013), they were expected to identify their developmental needs in meeting the role and responsibilities of a registered nurse. To contemplate skills and attributes associated with leadership specifically, students completed the NHS leadership framework self-assessment tool (NHS Leadership Academy 2012) with initial emphasis on the domains of demonstrating personal qualities and working with others. To capture their development needs, they formulated individual learning plans, which they were encouraged to revise throughout the module and incorporate academic developmental needs NURSING MANAGEMENT
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related to the coinciding final-year modules. The acquisition and identification of knowledge and skills were not confined to the academic aspect of the programme. For the students’ individual objectives, such as managing a bay of patients and being more assertive in delegation activities, to be realised, support from clinical colleagues is necessary so, as Allan (2010) suggests, staff in clinical areas need to ensure that students are exposed to examples of high functioning nurse leaders who demonstrate the qualities of good leaders.
Recommendations to develop leadership skills in practice Setting our future nurses on their leadership journeys in this module is of little relevance unless they are supported to develop and grow their burgeoning skills in practice as students, and beyond into registration. There are five key messages for today’s NHS nurse leaders: ■ Provide positive leadership role modelling. ■ Review with students the outcomes of their NHS leadership framework (NHS Leadership Academy 2012) self-assessments. ■ Assist students in assimilating their module learning-plan objectives into practice assessment learning objectives. ■ Encourage students to be active learners. ■ Give good quality feedback on students’ leadership skill development. Positive role models To learn the skills and practices of shared leadership, students need to see these in action, in practice, from role models throughout the organisations in which they work (Allan 2010). While it is evident there are some leadership failings across the healthcare sector (Berwick 2013, Francis 2013) to which the NHS Leadership Academy has responded, we believe positive leadership role models do exist across organisations and therefore should be accessible to all staff. The NHS leadership framework Identifying students’ leadership qualities by undertaking the NHS leadership framework (NHS Leadership Academy 2012) self-assessment tool supports and reinforces the spirit for creating a single leadership framework for all staff at any stage of their careers, which encourages shared responsibility for success, services or care (NHS Leadership Academy 2014). By encouraging development of the essential personal qualities, namely developing self-awareness, managing self, continuing personal NURSING MANAGEMENT
To learn the skills of shared leadership, students need to see these in action, in practice, from role models development and acting with integrity, the module recognises that the core essentials for leadership are embedded in practice. Undertaking the self-assessment and completing the action plans encourages students to establish where they are now, but also provides opportunities for reassessment and future development, for instance after their preceptorship year, while planning professional development and before applying for new positions. Planning to learn Students’ learning plans, written as part of the formative assessments during their university-based module, and achieved or partially achieved on their penultimate placements can enhance the practice assessment documents’ learning objectives; the plans do not detract from the practice areas defined as learning needs, but provide an additional opportunity for students to expand their leadership skills to be ‘practice ready’ in six months. Active learning The learning plan objectives, with chosen areas to develop identified by students, encourage them to become active learners and fosters a lifelong interest in learning that is engrained in our nursing code and vital for nurses to not merely function but succeed in our rapidly evolving healthcare system. Feedback Students need to develop their leadership styles with the support of mentors and all clinicians throughout the many practice settings in which they work. The students supernumerary status should not preclude them from actively participating in care delivery or impair their exposure to leadership experience; in fact, it could provide more opportunity to experiment and develop their leadership style and skills supported by mentors if planned in advance. They can grow only by experimenting, making mistakes and reflecting with guidance. This comes from honest and constructive feedback given in supportive environments.
Conclusion The drive to improve nursing leadership is multifaceted and demands collaborative approaches from all stakeholders, service providers and November 2014 | Volume 21 | Number 7 21
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Art & science | education educationalists. Shared, or distributed, leadership is an emerging role that views leadership in terms of collaboration and collective activity, and one that is being promoted as the future leadership model in health care (Block and Manning 2007). It is also reflected in the NHS leadership framework (NHS Leadership Academy 2014). In recognition of these drivers, an innovative framework for pre-qualifying nurses to develop leadership knowledge and skills was developed:
the LEAD framework. Students have understood leadership through the innovative approach of the module, and demonstrated leadership in practice. We conclude with a plea: let us feel excited about our students, brimming with enthusiasm about taking charge of their professional development and wanting to join our profession, and role model and reflect to them the knowledge, skills and practices that will help develop and shape our NHS into a healthier place.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Allan H (2010) The perils facing nurse education: a call for leadership for learning. Nurse Education Today. 30, 209-211. Banning M (2005) Approaches to teaching: current opinions and related research. Nurse Education Today. 25, 7, 502-508. Berwick D (2013) A Promise to Learn – A Commitment to Act. Improving the Safety of Patients in England. tinyurl.com/ot53wmh [Last accessed: September 2 2014.] Block LAM, Manning LJ (2007) A systematic approach to developing frontline leaders in healthcare. Leadership in Healthcare. 20, 2, 85-96. Bruner JS (2009) The Process of Education: Revised Edition USA. Harvard University Press, Cambridge MA. Burns JM (1978) Leadership. Harper and Row, New York NY. Carmen L, Rodeiro V, Nádas R (2011) Effects of Modularisation. Cambridge Assessment, Cambridge. Cherney ID (2008) The effects of active learning on students’ memories for course content. Active Learning in Higher Education. 9, 2, 152-171. Crevani L, Lindgren M, Packendorff J (2007) Shared leadership: a post-heroic perspective on leadership as a collective construction. International Journal of Leadership. 3, 1, 40-67. Elliott C, Stead V (2008) Learning from leading women’s experience: towards a sociological understanding. Leadership. 4, 2, 159-180. Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. www. midstaffspublicinquiry.com/report [Last accessed: August 29 2014.] Fulop L, Day GE (2010) From leader to leadership: clinician managers and where next? Australian Health Review. 34, 344-351. Gronn P (2008) The future of distributed leadership. Journal of Educational Administration. 46, 2, 141-158.
Hendricks JM, Cope VC, Harris M (2010) A leadership program in an undergraduate nursing course in Western Australia: building leaders in our midst. Nurse Education Today. 30, 252-257. Honey P, Mumford A (2006) The Learning Styles Questionnaire, 80-item Version. Peter Honey Publications, Maidenhead, Berkshire. Horsfall J, Clearly M, Hunt GE (2012) Developing a pedagogy for nursing teachinglearning. Nurse Education Today. 32, 930-933. Hsiu-Yueh Hsu, Lai-Liang Lee, Chia-Yun Fu et al (2011) Evaluation of a leadership orientation program in Taiwan: preceptorship and leader competencies of the new nurse manager. Nurse Education Today. 31, 809-814. Kapp S, Fergason J (2002) Contemporary students: learning styles and teaching strategies. American Academy of Orthotists and Prosthetists. 14, 2, 71-74. Khan P, O’Rourke K (2005) Understanding enquiry-based learning. In Barrett T, MacLabhrainn I, Fallon H (Eds) Handbook of Enquiry and Problem Based Learning. www.aishe.org/readings/2005-2/contents.html [Last accessed: August 29 2014.] Leigh JA, Rutherford J, Wild J et al (2012) Using patchwork text assessment as a vehicle for evaluating students’ perceptions of their clinical leadership development. Nurse Education in Practice. 12, 46-51.
Nagel C, Andenoro A (2012) Healing leadership: the serving leader’s impact on patient outcomes in a clinical environment. Journal of Healthcare Leadership. 4, 25-31.
Sharpe R, Benfield G, Roberts G et al (2006) The Undergraduate Experience of Blended E-learning: A Review of UK Literature and Practice. Higher Education Academy, York.
NHS Improving Quality (2013) Our Strategic Intent. NHS Improving Quality, London.
Slavich GM, Zimbardo PG (2012) Transformational teaching: theoretical underpinnings, basic principles, and core methods. Educational Psychology Review. 24, 4, 569-608.
NHS Institute for Innovation and Improvement (2007) Releasing Time to Care. NHS Institute for Innovation and Improvement, Coventry. NHS Leadership Academy (2012) Leadership Framework: Self-assessment Tool. tinyurl.com/ self-assess-tool [Last accessed: August 29 2014.] NHS Leadership Academy (2014) Healthcare Leadership Model: The Nine Leadership Dimensions. tinyurl.com/pescfa2 NHS Quality Observatory (2012) NHS Safety Thermometer. tinyurl.com/leco9ag [Last accessed: September 2 2014.] Nursing and Midwifery Council (2010) Standards for Pre-registration Nursing Education. NMC, London. Omoike O, Stratton KM, Brookes BA et al (2011) Advancing nurse leadership. A model for program implementation and measurement. Nurse Admin Quarterly. 35, 4, 323-332. O’Shea A (2003) Self-directed learning in nurse education: a review of the literature. Journal of Advanced Nursing. 43, 1, 62-70.
Machemer PL, Crawford P (2007) Student perceptions of active learning in a large cross-disciplinary classroom. Active Learning in Higher Education. 8, 1, 9-30.
Roebuck C (2011) Developing Effective Leadership in the NHS to Maximise the Quality of Patient Care. The Need for Urgent Action. King’s Fund, London.
MacPhee M, Skelton-Green J, Bouthillette F et al (2011) An empowering framework for nurse leadership development: supporting evidence. Journal of Advanced Nursing. 68, 1, 159-169.
Rogers R (2012) Leadership communication styles: a descriptive analysis of health care professionals. Journal of Health Care Leadership. 4, 47-57.
Meyer J, Land R, Baille C (2010) Threshold Concepts and Transformational Learning. Sense Publication, Rotterdam, Netherlands.
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Royal College of Nursing (2014) Supporting and Assisting People. tinyurl.com/p356tjj [Last accessed: September 2 2014.] Self Awareness LLP (2013) Understanding the Johari Window Model. tinyurl.com/klnahzt [Last accessed: August 29 2014.]
Tedesco-Schneck M (2012) Active learning as a path to critical thinking: are competencies a roadblock? Nurse Education in Practice. dx.doi.org/10.1016/j.nepr.2012.07.007 Toynton R (2005) Degrees of disciplinarity in equipping mature students in higher education for engagement and success in lifelong learning. Active Learning in Higher Education. 6, 2, 106-117. Turnbull James K (2011) Leadership in Context. Lessons from New Leadership Theory and Current Leadership Development Practice. King’s Fund, London. West M, Farr JL (1990) Innovation at work. In MA West, JL Farr (Eds) Innovation and Creativity at Work: Psychological and Organizational Strategies. John Wiley & Sons, Chichester. Willis Commission (2012) Quality with Compassion: The Future of Nursing Education. Report of the Willis Commission on Nursing Education. Royal College of Nursing, London. Wilson DS, Redman RW, Potempa KM (2010) A vision and compass for health care leadership: lessons from the migrant nurse resolution for recurrent nursing shortages. Journal of Healthcare Leadership. 2, 91-96. Wright RR, Sandlin JA (2009) Cult TV, hip hop, shape-shifters, and vampire slayers: a review of the literature at the intersection of adult education and popular culture. Adult Education Quarterly. 59, 2, 118-141. Young MS, Robinson S, Alberts P (2009) Students pay attention! Combating the vigilance decrement to improve learning during lecturers. Active Learning in Higher Education. 10, 1, 41-55.
NURSING MANAGEMENT
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The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
A FRAMEWORK FOR PRE-QUALIFYING NURSES TO BUILD LEADERSHIP SKILLS Karen Buckwell-Nutt and colleagues describe the development of an innovative module to help students become better leaders Correspondence [email protected] Karen Buckwell-Nutt is head of academic department, pre-qualifying nursing Jayne Francis-Shama is a senior lecturer, pre-qualifying nursing Pollyanna Kellett is a senior lecturer, pre-qualifying nursing All at the faculty of society and health, Buckinghamshire New University Date of submission July 1 2014 Date of acceptance August 26 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ nm-author-guidelines
Abstract Nursing students are our future leaders in the healthcare sector. It is proposed that, for students to understand and demonstrate leadership knowledge, skills and attributes effectively, they need to: learn concepts, experience leadership roles, analyse their capabilities and develop these with the support of practitioners. The drive to improve nursing leadership does not come from within academia but from practitioners and other stakeholders, such as patients, the Nursing and Midwifery Council and Health Education England, and this need is reflected in the university curriculum. This article reviews a final-year module on personal development for leadership and management and highlights the
Contemporary leadership in the NHS INEFFECTIVE LEADERSHIP has become the focus of blame for some failings in the NHS (Francis 2013). This has been accentuated by the challenge of delivering consistently high quality patient care in today’s demanding and complex healthcare landscape (Nagel and Andenoro 2012). Leadership style has influenced the development of leadership in nursing for decades. For example, transformational and transactional leadership emerged in the 1990s as the dominant framework (Rogers 2012) following Burn’s (1978) seminal work. This emphasised the individualist role and heroic view of leaders as nurturing, motivated individuals who can encourage innovation and creativity in teams. However, despite the
16 November 2014 | Volume 21 | Number 7
importance of continued practice support in developing leadership skills and confidence. The educational approaches, including lectures, the use of problembased scenarios and enquiry-based learning, are explored and the inclusion of e-learning methods is discussed. Students are made aware that placement expectations are different from those in previous years. Recommendations include strategies to strengthen practice support for students who need to develop leadership skills. Keywords Leadership, pre-registration nurse education, academia, shared leadership, distributed leadership, quality promotion of a transformational leadership style, the rigid hierarchical structure of the NHS has prohibited an effective approach to leadership (Roebuck 2011). This problem has not been overcome, but the model proposed here aids students to challenge more. Nurse leadership is going through unprecedented change, heightened by a view that a shared model of leadership should be integrated into the profession (Fulop and Day 2010, MacPhee et al 2011). Shared, or distributed, leadership is an emerging role that views leadership in terms of collaboration and collective activity that no longer embraces the heroic individual leader. It is this view that is being promoted as the NURSING MANAGEMENT
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Art & science | education In nurse education, recognition of the importance of leadership is not addressed until students are within months of qualifying future leadership model in health care (Block and Manning 2007). The concept of shared leadership is reflected in the current NHS leadership framework (NHS Leadership Academy 2014), which provides a consistent approach to leadership development for all staff in health care irrespective of discipline, role or seniority. The NHS leadership framework, titled the Healthcare Leadership Model, represents the standard for leadership behaviours to which all staff should aspire. Fundamental to the development of the Healthcare Leadership Model is a desire to create a single, overarching framework for all health and care staff, building on best-practice standards for leadership development (NHS Leadership Academy 2014). The shared leadership model is different from the traditional individualistic models of leadership (Turnball James 2011). According to the Healthcare Leadership Model, rather than focus on a set of personal attributes, leaders are to be supported by a network of people engaging in leadership practices throughout the organisation (Elliott and Stead 2008, Gronn 2008, Turnball James 2011). The new shared leadership role is embedded in a culture of collaboration, partnership working and reduced hierarchy, with individuals displaying effective interpersonal skills and an ability to deal with conflict (Crevani et al 2007, Fulop and Day 2010). Leadership in pre-registration nurse education therefore faces immense challenges to develop undergraduate nurses with the ability and drive to promote a shared leadership culture in the profession. The preparation of leaders who will make the types of decisions needed in today’s complex healthcare environment requires innovative approaches to learning (Wilson et al 2010). With the focus on patient outcomes and safety, it is imperative that preceptee nurses enter practice settings with leadership capabilities (Hendricks et al 2010). In nurse education in the UK, recognition of the importance of leadership is not addressed until students are within months of qualifying. This results in undergraduate nurses entering clinical environments unprepared to take on leadership demands. In light of this, there is a call for undergraduate nurse training programmes to 18 November 2014 | Volume 21 | Number 7
implement leadership at each level of the course to embed in students a growing interest in and realistic perspective of the demands of leadership (Hendricks et al 2010).
Pedagogical considerations There are varying components that universities have recognised as essential to the development of leadership awareness and adult learning principles, including communication skills and conflict (Hsiu-Yueh et al 2011). However, a clear Nursing and Midwifery Council (NMC) (2010) directive about the leadership qualities of nurses calls for fundamental elements to be in place. Universities and clinical areas that support undergraduate nursing students must collaborate as each setting can offer students differing perspectives on leadership (Allan 2010). First, universities need to meet the pedagogic needs of students, ensuring that differing learning styles are addressed and innovative teaching is provided. Second, clinical areas need to ensure that students are exposed to examples of high functioning nurse leaders who demonstrate the qualities of a leader. Traditional pedagogy has centred on teacher-dominated perspectives, with the transfer of information to students in a pre-determined manner (Horsfall et al 2012, Tedesco-Schneck 2012). This style of pedagogy, which relies on recall and factual forms of knowledge, has attracted criticism around its inability to reduce the gap between what is taught in classrooms and the realities of clinical practice (Leigh et al 2012). Traditionally the ‘talk and chalk’ lecture method (Young et al 2009) presents to students a passive form of learning that achieves engagement for a minimum amount of time and fails to promote deep learning (Toynton 2005, Machemer and Crawford 2007, Cherney 2008). The constructivist view of learning suggests that a teacher lecturing to a class may not always be the most effective way for adult students to learn (Kapp and Fergason 2002). Contemporary pedagogical theory, therefore, aims to promote leadership development through the incorporation of a unifying theoretical framework that links to nursing practice and research and that provides the basis for decision making with regard to content (MacPhee et al 2011). When considering the complex nature of leadership, an experiential learning approach to encourage students to critically evaluate concepts, think laterally and apply theoretical positions during problem-solving exercises is more productive (Banning 2005). The experiential NURSING MANAGEMENT
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learning approach allows the transition of knowledge into clinical settings. The NMC (2010) has included leadership and team working in its revised standards for pre-registration nursing education. Here the aim, as a generic standard of competence, is for all nurses to qualify with an ability to provide leadership in managing nursing care and to co-ordinate interprofessional care when needed. In support of this, Willis (Willis Commission 2012) documents the significance of leadership in nursing curricula. Importantly, the exposure to skilled, positive leadership role modelling is identified as critical to developing leadership knowledge in undergraduate students (Omoike et al 2011, Willis Commission 2012). The challenges for curriculum development at Buckinghamshire and more generally were clear: to help students understand shared leadership, which has emerged as the future model for the NHS (Block and Manning 2007); and to enable them to incorporate and develop this into their own emergent leadership style. With a need to provide students with important leadership and management skills in a university setting to prepare them for practice as third-year nursing students, and beyond to their preceptorship and future years as registered nurses, the imperative is to bridge the theory-practice gap and bring contemporary leadership issues into the classroom for discussion and analysis in a safe environment. The demands of nurse education are multifaceted and the debate on its effectiveness continues. Meanwhile, there is a requirement for graduate nurses to achieve additional skills relating to leadership (NMC 2010), including an ability to: ■ Act as change agents and provide leadership through high quality systems. ■ Identify priorities, and manage time and resources effectively. ■ Take the lead in co-ordinating, delegating and supervising care safely. ■ Manage risk and remain accountable for the care given. ■ Maintain their personal and professional development. To address these leadership requirements, a module entitled Personal Development for Leadership and Management was developed at Buckinghamshire. Transformational learning The educational framework underpinning the module is transformational learning. The precepts of this approach involve students experiencing a shift of understanding. This shift is not independent NURSING MANAGEMENT
of content, context or discipline, and any activity or resource that presents students with alternative views to their own can be used (Meyer et al 2010). It requires lecturers to create dynamic relationships between themselves, the students and the ‘body of knowledge’ to promote students’ understandings and personal development (Slavich and Zimbardo 2012). The module team used a spiral curriculum approach (Bruner 2009), which posits that students should revisit a concept or skill regularly but that each time the complexity increases and that any new learning relates to old understanding. As this is a final-year module and was aimed at building on students’ knowledge and skills already acquired in the programme, a progressive themed approach was adopted. This is explained as moving students from current understandings towards identification of new knowledge and skills, thereby developing these skills in clinical settings. This approach, in part, addresses the limitations of modular programmes, namely that they are fragmented (Carmen et al 2011). Various activities were designed to accommodate different learning styles (Honey and Mumford 2006). Box 1 Examples of activities and content Learn
Accountability, delegation, leadership theories and styles, conflict management, principles of managing resources, emotional intelligence preceptorship, employability.
Experience
Problem-based scenarios involving, for example, staff allocation, prioritising care, communication, complaint management, presenting innovative practice, clinical management in placement.
Analyse
Strengths, weaknesses, opportunities and threats (SWOT) analysis, Johari windows, leadership framework self-assessment tools, interview critique, problem solving self-assessment.
Develop
Creation and implementation of learning plans, negotiation skills, communication skills, practice leadership and management skills with support of practitioners. November 2014 | Volume 21 | Number 7 19
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Art & science | education Innovative design framework The Learn, Experience, Analyse, Develop (LEAD) framework was created to design the module flow and the presentation of content. See Box 1 for examples of activities and content. The module delivery consisted of seminars, lead lectures, e-learning activities and an employability day. The small group seminars enabled discussions of key themes and exploration of a three-stage field-specific, problem-based clinical leadership scenario. Through the use of problem-based scenario activities, students were encouraged to explore concepts, think creatively and apply solutions during problem-solving exercises (Banning 2005). During lead lectures, new concepts, including theories of leadership and conflict management, were introduced. Students had the opportunity to explore and test the new concepts further during the problem-based seminars and preceptorship. While the traditional teacher-centred lecture method could be criticised for its transmission of information to the passive student, this opportunity for large group teaching is economically justified. By adopting an interactive style in the one-hour lectures, students had the opportunity to be less passive. As well as using a question-and-answer technique, the inclusion of popular culture, for example reference to common activities such as the use of mobile telephones or social media networks, and artefacts from mass media, such as current soap opera storylines or recent news headlines, enabled the lecturer to ‘connect with the adult learner’ (Wright and Sandlin 2009). The virtual learning environment (VLE) was carefully structured to make explicit the prerequisites for classroom-based sessions and suggested additional independent learning activities with which students could chose to engage. The e-learning activities were congruent with the themes addressed each week in the classroom sessions. Sharpe et al (2006) suggest that students need to understand the use of technology in their learning and that educators need to be consistent and transparent in communicating their expectations to students. The expectation that students engage with the VLE materials was made clear at the beginning of the module and reinforced throughout by the seminar lecturer. For the VLE and seminars to be effective, students are required to self-regulate their learning. O’Shea (2003) suggests that nurse educators must help nurses develop the skill of self-regulated 20 November 2014 | Volume 21 | Number 7
learning so they can meet the challenges of constantly changing healthcare environments. Nursing innovations The NMC (2010) requires graduate nurses to act as change agents and provide leadership through good quality systems. To consider innovation and implementation of change in practice, students were guided through an enquiry-based learning (EBL) method (Khan and O’Rourke 2005) to explore important innovative practices appropriate to their fields of nursing; these might include use of the safety thermometer (NHS Quality Observatory 2012), red-tray system (Royal College of Nursing (RCN) 2014) or the Productive Ward initiative (NHS Institute for Innovation and Improvement 2007). Through this process, students seek evidence to support ideas triggered by a topic and take responsibility for analysing and presenting this evidence to peers in their seminar group. NHS Improving Quality (2013) advocates staff empowerment and proposes innovative ways of delivering good quality services. The RCN supports the definition of innovation offered by West and Farr (1990) as ‘the intentional introduction and application within a role, group or organization of ideas, processes, products or procedures, new to the relevant unit of adoption, designed to significantly benefit the individual, the group, the organization or wider society’. The transferable skills required to source, analyse and present evidence are fundamental to developing confidence to challenge and change practice. Increasing awareness Initially, students were required to revisit their understanding of healthcare assistant (HCA), nursing student and registered nurse roles and responsibilities, and the concept of accountability and delegation. Through the use of self-evaluative tools, strengths, weaknesses, opportunities and threats (SWOT) analysis and Johari windows (Self Awareness LLP 2013), they were expected to identify their developmental needs in meeting the role and responsibilities of a registered nurse. To contemplate skills and attributes associated with leadership specifically, students completed the NHS leadership framework self-assessment tool (NHS Leadership Academy 2012) with initial emphasis on the domains of demonstrating personal qualities and working with others. To capture their development needs, they formulated individual learning plans, which they were encouraged to revise throughout the module and incorporate academic developmental needs NURSING MANAGEMENT
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related to the coinciding final-year modules. The acquisition and identification of knowledge and skills were not confined to the academic aspect of the programme. For the students’ individual objectives, such as managing a bay of patients and being more assertive in delegation activities, to be realised, support from clinical colleagues is necessary so, as Allan (2010) suggests, staff in clinical areas need to ensure that students are exposed to examples of high functioning nurse leaders who demonstrate the qualities of good leaders.
Recommendations to develop leadership skills in practice Setting our future nurses on their leadership journeys in this module is of little relevance unless they are supported to develop and grow their burgeoning skills in practice as students, and beyond into registration. There are five key messages for today’s NHS nurse leaders: ■ Provide positive leadership role modelling. ■ Review with students the outcomes of their NHS leadership framework (NHS Leadership Academy 2012) self-assessments. ■ Assist students in assimilating their module learning-plan objectives into practice assessment learning objectives. ■ Encourage students to be active learners. ■ Give good quality feedback on students’ leadership skill development. Positive role models To learn the skills and practices of shared leadership, students need to see these in action, in practice, from role models throughout the organisations in which they work (Allan 2010). While it is evident there are some leadership failings across the healthcare sector (Berwick 2013, Francis 2013) to which the NHS Leadership Academy has responded, we believe positive leadership role models do exist across organisations and therefore should be accessible to all staff. The NHS leadership framework Identifying students’ leadership qualities by undertaking the NHS leadership framework (NHS Leadership Academy 2012) self-assessment tool supports and reinforces the spirit for creating a single leadership framework for all staff at any stage of their careers, which encourages shared responsibility for success, services or care (NHS Leadership Academy 2014). By encouraging development of the essential personal qualities, namely developing self-awareness, managing self, continuing personal NURSING MANAGEMENT
To learn the skills of shared leadership, students need to see these in action, in practice, from role models development and acting with integrity, the module recognises that the core essentials for leadership are embedded in practice. Undertaking the self-assessment and completing the action plans encourages students to establish where they are now, but also provides opportunities for reassessment and future development, for instance after their preceptorship year, while planning professional development and before applying for new positions. Planning to learn Students’ learning plans, written as part of the formative assessments during their university-based module, and achieved or partially achieved on their penultimate placements can enhance the practice assessment documents’ learning objectives; the plans do not detract from the practice areas defined as learning needs, but provide an additional opportunity for students to expand their leadership skills to be ‘practice ready’ in six months. Active learning The learning plan objectives, with chosen areas to develop identified by students, encourage them to become active learners and fosters a lifelong interest in learning that is engrained in our nursing code and vital for nurses to not merely function but succeed in our rapidly evolving healthcare system. Feedback Students need to develop their leadership styles with the support of mentors and all clinicians throughout the many practice settings in which they work. The students supernumerary status should not preclude them from actively participating in care delivery or impair their exposure to leadership experience; in fact, it could provide more opportunity to experiment and develop their leadership style and skills supported by mentors if planned in advance. They can grow only by experimenting, making mistakes and reflecting with guidance. This comes from honest and constructive feedback given in supportive environments.
Conclusion The drive to improve nursing leadership is multifaceted and demands collaborative approaches from all stakeholders, service providers and November 2014 | Volume 21 | Number 7 21
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Art & science | education educationalists. Shared, or distributed, leadership is an emerging role that views leadership in terms of collaboration and collective activity, and one that is being promoted as the future leadership model in health care (Block and Manning 2007). It is also reflected in the NHS leadership framework (NHS Leadership Academy 2014). In recognition of these drivers, an innovative framework for pre-qualifying nurses to develop leadership knowledge and skills was developed:
the LEAD framework. Students have understood leadership through the innovative approach of the module, and demonstrated leadership in practice. We conclude with a plea: let us feel excited about our students, brimming with enthusiasm about taking charge of their professional development and wanting to join our profession, and role model and reflect to them the knowledge, skills and practices that will help develop and shape our NHS into a healthier place.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
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