management education Art & science | xxx
Evaluation of a nurse leadership development programme Margaret West and colleagues describe the creation of the Nurses Emerging as Leaders programme and analyses its effectiveness Correspondence [email protected] Margaret West is director of system nursing research, Geisinger Health System, Nursing Education Center, Danville, Pennsylvania Lisa Smithgall is vice president of patient care services, and chief nursing officer, Holston Valley Medical Center, Kingsport, Tennessee Greta Rosler is patient care manager, Geisinger Medical Center, Danville, Pennsylvania Erin Winn is human resources administrator, Geisinger Medical Center, Danville, Pennsylvania
Date of submission November 25 2015 Date of acceptance January 26 2016 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines journals.rcni.com/r/ nm-author-guidelines
Abstract The challenge for nursing leaders responsible for workforce planning is to predict the knowledge, skills and abilities required to lead future healthcare delivery systems effectively. Succession planning requires a constant, competitive pool of qualified nursing leader candidates, and retention of those interested in career growth. Formal nursing leadership education in the United States is available through graduate education and professional nursing organisation programmes, such as the Emerging Nurse Leader Institute of the American Organization of Nurse Executives. However, there is also a need for local development programmes tailored to the DEVELOPING, ADVANCING and evaluating nursing leadership competency can improve clinical outcomes for patients and build high-performing nursing teams. Successful nurse leaders must be responsive, demonstrate flexibility, apply the concepts of leadership effectively, and know how to make personal connections. The Nurses Emerging as Leaders (NEL) programme at Geisinger Health System, one of the largest rural health systems in the US, helps to establish and develop these attributes. Many healthcare institutions highlight the lack of leadership skills and preparedness of nurse leaders to meet the challenges of evolving healthcare environments (Bondas 2006). Formal education through master’s programmes can provide an excellent foundation on which to build these skills, but leaders also must meet the specific needs of healthcare institutions. Identifying and preparing nursing leaders for operational and patient care unit management, as well as system leadership, can be challenging, particularly in rural areas with limited human resources.
26 March 2016 | Volume 22 | Number 10
needs of individual organisations. Leaders at Geisinger Health System, one of the largest rural health systems in the US, identified the need for an internal professional development scheme for nurses. In 2013 the Nurses Emerging as Leaders programme was developed to prepare nurse leaders for effective leadership and successful role transition. This article describes the programme and an evaluation of its effectiveness. Keywords leadership, leader development, leadership education, management, workforce planning Before the development of the NEL programme, the identification and preparation of nurses for leadership positions at Geisinger depended on many factors, including individuals’ work experience and educational preparation, level of mentorship and the culture of the working environment. Executive nursing leaders recognised that previous methods were inconsistent and ineffective, and at times resulted in new leaders being unsuccessful. The goal, therefore, was to formalise nursing leadership preparation. Staff in the Geisinger human resources (HR) department analysed future retirement and growth expectations in nursing management positions to predict turnover. Based on average retirement age, results showed turnover expectations of more than 30% for the next ten to 15 years, so, with support from leaders in nursing and HR, a plan was created to develop an internal nursing leadership programme. A development team of HR specialists, and executive and operational nursing leaders from across the health system, created a tailored, flexible NURSING MANAGEMENT
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educational programme to meet succession planning needs at various leadership levels. The aims were to invest in potential nurse leaders and retain them in the organisation, and to develop a more prepared and competitive group of candidates for future nursing leadership opportunities. The programme’s curricular framework is based on a combination of the Geisinger leadership competencies and three of the American Organization of Nurse Executives (AONE) (2011) nursing executive competencies (Table 1). The Geisinger leadership competencies model, developed to ensure continuous improvement in people and processes, provides a baseline of expected skills and behaviours for all leaders. It comprises seven domains, each of which includes a definition and examples of behaviour that demonstrate achievement of the core leadership competency. The domains are: ■■ Inspiring engagement. ■■ Driving results. ■■ Influential leadership. ■■ Promoting teamwork and collaboration. ■■ Leading change and innovation. ■■ Advocating excellence. ■■ Strategic planning and implementation. The AONE nurse executive competencies comprise the following domains: ■■ Communication and relationship building. ■■ Knowledge of the healthcare environment. ■■ Leadership. ■■ Professionalism. ■■ Business skills. Each AONE competency domain includes a list of skills common to nurses in executive practice and applicable to nurse leaders at all levels of a healthcare organisation. The degree of competency is dependent on each individual leader’s position.
Educational structure The NEL programme takes a year to complete. Participants attend one, eight-hour education day every four to six weeks, and this focuses on one of the leadership competencies. The educational content of the sessions includes, but is not limited to, transition into leadership, HR leadership, leading change, influential leadership, finance, quality, strategic planning, and regulatory and professional issues. As well as educational presentations on global and leadership theory, each session includes complementary presentations, delivered by experienced nurse leaders, on the application of theory to nursing and to patient care unit management, and discussions about individuals’ leadership journeys. NURSING MANAGEMENT
Participants are given reading assignments to complete before each NEL session, and attend additional educational programmes. Undertaking these extra learning activities enhances participants’ preparation and supports their leadership competency development. Application of taught theory and competencies is supported through the project component of the programme. Each participant is assigned a mentor and given guidance on identifying and completing a project that uses their newly acquired knowledge and skills. They then share their learning with the rest of the group. The programme is designed to allow time for networking with other participants, and to meet other leaders throughout the healthcare system. Programme participant selection is based on set criteria. For example, a written application describing goals and views on effective leadership must be submitted, with examples of how candidates lead improvements. A formal recommendation from an immediate supervisor confirming high performance in a supervisory role must also be obtained. In addition, a bachelor of science in nursing degree is a minimum educational qualification. Participant numbers are limited to between 16 and 18 a year, which fosters competition among potential nurse leaders, and in general fewer than half the applicants are accepted on to the programme.
Succession planning needs The NEL programme retains the same goals each year but is adapted to meet the succession planning needs of the organisation. Programme ‘focus’ is determined jointly by the development team and the organisation’s nurse leaders. In 2014, the NEL programme focused on nurses, such as team co-ordinators, team leaders or clinic nurse supervisors, who are already in established supervisory roles and were interested in moving to the next level of nursing leadership. However, as the programme progressed, nursing leaders identified the need to develop nurses who wanted to prepare for a first supervisory role. A similar process of turnover analysis, exploration of growth expectations and recruitment efforts was undertaken, which confirmed the need to adapt the programme and offer it to this level of participant to support the organisation’s emerging needs. The adapted programme was rolled out in 2015 and focused on nurses who demonstrated excellent informal leadership and wanted to prepare for a first supervisory opportunity, such as a team co-ordinator or nurse supervisor. Applicants who demonstrated high levels of competence as charge March 2016 | Volume 22 | Number 10 27
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Art & science | management education Table 1
The Geisinger leadership competencies and three of the American Organization of Nurse Executives nurse executive competencies
Geisinger leadership competencies
American Organization of Nurse Executives nurse executive competencies
Communication and relationship building
Knowledge of the healthcare environment
Leadership
Inspiring engagement
■■ Relationship management ■■ Influencing behaviours ■■ Shared decision making ■■ Medical staff relationships
■■ Clinical practice knowledge ■■ Delivery models and work design
■■ Systems thinking ■■ Succession planning ■■ Change management ■■ Personal and professional accountability
Driving results
■■ Medical staff relationships
■■ Healthcare economics
■■ Change management ■■ Personal and professional accountability ■■ Financial management ■■ Human resource management
Influential leadership
■■ Effective communication ■■ Relationship management ■■ Medical staff relationships
■■ Delivery models and work design ■■ Evidence-based practice and outcome measurement
■■ Foundational thinking skills ■■ Personal journey and disciplines ■■ Systems thinking ■■ Succession planning ■■ Change management ■■ Personal and professional accountability
Promoting teamwork and collaboration
■■ Effective communication ■■ Shared decision making ■■ Community involvement ■■ Medical staff relationships ■■ Academic relationships
Leading change and innovation Advocating excellence
■■ Delivery models and work design
■■ Medical staff relationships ■■ Academic relationships
Strategic planning and implementation
Competencies without Geisinger counterpart
■■ Human resource management
■■ Diversity
28 March 2016 | Volume 22 | Number 10
■■ Clinical practice knowledge ■■ Delivery models and work design ■■ Evidence-based practice and outcome measurement ■■ Patient safety ■■ Quality improvement and metrics ■■ Risk management
■■ Evidence-based practice and outcome measurement
■■ Healthcare economics ■■ Healthcare policy ■■ Governance
■■ Advocacy ■■ Strategic management
■■ Utilisation and case management ■■ Career planning ■■ Ethics ■■ Active membership in professional organisations ■■ Marketing ■■ Information management and technology
NURSING MANAGEMENT
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nurses or preceptors, and who were already engaged in shared governance activities, were selected. The programme’s content and project work are adapted to suit the appropriate level of professional development for each individual. Such flexibility also provides opportunities for nurses at various points on the leadership pathway, and creates an internal pool of candidates able to meet the various recruitment needs of the organisation.
Evaluation of content At the end of the NEL programme, participants are emailed a feedback tool comprising open‑ended questions. They are asked to evaluate the course content and its relevance to their leadership development and goals, to define how the learning has affected their leadership style and activities, describe what elements are most and least effective, and suggest topics they think should be included. Participants are also asked to suggest additional professional development topics they might find beneficial at future NEL retreats or reunions for the programme’s graduates. Feedback from the first two groups was positive. Most participants said they appreciated all aspects of the course, and expressed their wish to be invited to future sessions. Many commented that more practical sessions on finance would be useful, as would further learning about difficult conversations and conflict. The nursing leadership team evaluated whether participation affected nurse leaders’ competencies compared with those who had not taken part. The study protocol was reviewed and approved by the Geisinger Health System institutional review board. Two of the questions posed were: ■■ Was there a difference in the competency scores of nurse leaders who completed the NEL programme compared to those who did not take part? ■■ Do nurses who work with these leaders perceive any difference between the two groups? Two leadership inventories were used to assess the nurse leader participants’ change in practice and behaviours: the Leadership Practices Inventory (LPI) (Kouzes and Posner 2003), and the Nurse Manager Skills Inventory (NMSI) (Nurse Manager Leadership Collaborative (NMLC) 2004). Nurse leader participants completed the LPI ‘self’ survey and the NMSI, and staff members completed the LPI ‘observer’ survey. Ten months after the end of the programme, 15 NEL nurse leaders and 15 non-NEL nurse leaders were invited to complete the LPI self survey and the NMSI. Two qualified nurses completed the LPI NURSING MANAGEMENT
observer survey for each NEL nurse leader and for each non-NEL nurse leader, so that a comparison could be made between staff evaluation of the programmes’ participants and non-participants. The Kouzes and Posner theoretical framework (Kouzes and Posner 1998, 2006, 2007, 2013) incorporates five fundamental practices of exemplary leadership, each delineated by statements that provide a guide to desired leadership behaviours: ■■ Challenging the process: searching for opportunities, experimenting and taking risks. ■■ Inspiring a shared vision: envisioning the future and enlisting the support of others. ■■ Enabling others to act: fostering collaboration and strengthening others. ■■ Modeling the way: setting an example and planning small successes. ■■ Encouraging the heart: recognising contributions and celebrating accomplishments. These practices form the basis of Kouzes and Posner’s LPI (2013), which measures charge nurse leadership. This tool was selected because it provides concurrent measurement of nurse leaders’ perceptions of their leadership abilities and staff’s perceptions of their nurse leader’s leadership abilities. The LPI is a 30-item Likert-style scale from 1 (low) to 5 (high), with a range of summed scores from 30 to 150. Kouzes and Posner’s method of test administration consists of matching a self subject with observer subjects. The instruments have been tested for reliability and validity by more than 36,000 multinational subjects and have a reported Cronbach’s alpha range of between .70 and .85 for the self instrument, and .81 and .92 for the observer version (Posner and Kouzes 1988, 1993, 2014).
Nurse manager skills inventory The NMLC Learning Domain Framework (NMLC 2006) is a competency model widely used for nursing leadership development at unit level; unit‑level nurse leaders work as operations managers or team leaders rather than at higher executive levels. To address the need for leadership development, AONE, the Association of periOperative Registered Nurses, and the American Association of Critical‑Care Nurses, collaborated to develop the framework to identify competency domains required by current and future nurse leaders. In addition, the NMSI (NMLC 2004) outlines the main skills needed by nurse managers in each competency domain area, and can be used to develop charge nurses, team leaders and emerging leaders. It also allows nurses to use Benner’s (1985) March 2016 | Volume 22 | Number 10 29
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Art & science | management xxx education Figure 1 Comparison scores between leaders who undertook the Nurses Emerging as Leaders programme and those who did not 300 -
Non-NEL leader NEL leader
250 -
Results
200 150 100 50 0
LPI Observer
LPI Self
NMSI
NEL = Nurses Emerging as Leaders LPI = Leadership Practices Inventory NMSI = Nurse Manager Skills Inventory five novice-to-expert stages of skill acquisition. The three domains of the NMLC framework also provide a useful structure for focusing development activities on growing nurse leaders at unit level: ■■ Domain 1 is ‘the leader within: creating the leader in yourself’. ■■ Domain 2 is ‘the art of leadership: leading people’. ■■ Domain 3 is ‘the science of leadership: managing the business’. Successful nurse managers must gain some level of expertise in all three domains. Often nurse leaders have no formal leadership education before taking on their first leadership role, and are generally promoted based on clinical expertise and effectiveness. Taking on a nursing leadership role reduces clinical experts to novices, and progression towards, and attainment of, expert level practice is not guaranteed. Benner’s (1985) stages of skill acquisition provide a framework to support nursing leadership development with theoretical knowledge and practical application. The movement from novice to expert nursing leader is characterised by the transition from leaders who function primarily with rulegoverned behaviours, to those who demonstrate intuitive, contextually determinate behaviours (Altmann 2007). Competency models also provide frameworks for the design and implementation of leadership 30 March 2016 | Volume 22 | Number 10
development programmes, and there is a range that can be explored (Sherman et al 2007, Calhoun et al 2008, Huston 2008, Supamanee et al 2011). However, the Geisinger NEL is based on Kouzes and Posner’s competency models, the NMLC learning domain framework, and Benner’s novice-to-expert framework.
The results of the inventory surveys will be used to develop NEL programme content, and will be compared with participants’ feedback to improve the programme’s relevancy to leaders’ learning needs. To evaluate the effectiveness of the NEL programme, each of the items in the LPI observer, LPI self and NMSI surveys were compared between the NEL participants and staff, and non-NEL participants and staff. The data show that NEL nursing leaders received higher scores in the LPI self and the LPI observer surveys (Figure 1). The LPI self and LPI observer questions that showed the greatest improvement among NEL participants are shown in Box 1. NEL programme participants also showed improvement in the NMSI survey subcategories (Figure 2). The NMSI questions that showed the greatest improvement among NEL participants are listed in Box 2: nine were from the ‘managing the Box 1 Leadership Practices Inventory questions showing the greatest improvement among programme participants Self questions Q8 I challenge people to try out new and innovative ways to do their work Q12 I appeal to others to share an exciting dream of the future Q16 I ask for feedback on how my actions affect other people’s performance Q22 I paint the big picture of what we aspire to accomplish Q28 I experiment and take risks, even when there is a chance of failure Observer questions Q12 Appeals to others to share an exciting dream of the future Q23 Makes certain that we set achievable goals, make concrete plans, and establish measurable milestones for the projects and programmes that we work on Q26 Is clear about his/her philosophy of leadership Q27 Speaks with genuine conviction about the higher meaning and purpose of our work NURSING MANAGEMENT
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business’ section and two were from the ‘creating the leader in yourself’ section.
Conclusion Delivering optimal patient care and outcomes in ever-changing healthcare environments depends on organisations’ ability to support successful transition of individuals into nursing leadership roles. The NEL programme improves succession planning by developing leaders from within Geisinger’s nursing teams, who are then well prepared for promotion when leadership positions become available. Having knowledgeable nursing leaders with the skills to undertake their role successfully will increase levels of personal satisfaction and morale, which also increases the likelihood of retention. Identifying mentors for new leaders is a crucial supplement to education, and provides Figure 2 Subcategories of Nurse Manager Skills Inventory survey 140 -
Non-NEL leader NEL leader
120 100 80 60 40 20 0 Managing
Leading
Creating
NEL = Nurses Emerging as Leaders
Box 2 Nurse Manager Skills Inventory questions showing the greatest improvement among programme participants ■■ Understanding of healthcare economics and healthcare public policy as it applies to the delivery of patient care ■■ Keeping commitments to oneself ■■ Creating and managing a budget ■■ Ability to alter roles based on changing department and healthcare environment needs ■■ Expense forecasting ■■ Identification of important skills and attributes for each role ■■ Diversity as a vehicle to wholeness ■■ Monitoring a budget ■■ Creating a budget ■■ Interpreting financial information ■■ Department-based budgeting opportunities for role modeling, situational sharing and discussion, and coaching and support, thus supporting effective transition to operational unit leadership roles. In addition, mentoring promotes continuous leadership development and competency education, real-time problem solving, and development of critical thinking. Further evaluation of the NEL programme is required to ensure the content remains current, and that individuals’ goals and the organisation’s succession planning needs are met. Growing nurse leaders is a long-term project that requires planning and action. The most significant contribution leaders can make to the future of nursing is to develop their successors. Emerging leaders will eventually replace them and continue the vital work being done to improve nursing environments and, most importantly, patient outcomes.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Altmann T (2007) An evaluation of the seminal work of Patricia Benner: theory or philosophy? Contemporary Nurse. 25, 1-2, 114-123.
Huston C (2008) Preparing nurse leaders for 2020. Journal of Nursing Management. 16, 8, 905-911.
Kouzes J, Posner B (2013) LPI: The Leadership Practices Inventory Workbook. Pfieffer, San Francisco CA.
American Organization of Nurse Executives (2011) AONE Nurse Executive Competencies. AONE, Chicago IL.
Kouzes J, Posner B (1998) The Leadership Practices Inventory. First edition. Pfeiffer, San Diego CA.
Nurse Manager Leadership Collaborative (2004) Nurse Manager Skills Inventory. tinyurl. com/hbtdy59 (Last accessed: February 9 2016.)
Benner P (1985) From Novice to Expert, Excellence and Power in Clinical Nursing Practice. Seventh edition. Addison-Wesley, Menlo Park CA.
Kouzes J, Posner B (2003) Leadership Practices Inventory. Fourth edition. Pfieffer, Wiley & Sons, San Diego CA.
Nurse Manager Leadership Collaborative (2006) NMLC Learning Domain Framework. tinyurl.com/jsjlp32 (Last accessed: February 9 2016.)
Bondas T (2006) Paths to nursing leadership. Journal of Nursing Management. 14, 5, 332-339. Calhoun J, Dollett L, Sinioris M et al (2008) Development of an interprofessional competency model for healthcare leadership. Journal of Healthcare Management. 53, 6, 375-391.
NURSING MANAGEMENT
Kouzes, J, Posner B (2006) Leadership Legacy. First edition. Josey-Bass, San Francisco CA. Kouzes J, Posner B (2007) The Leadership Challenge: How to Keep Getting Extraordinary Things Done in Organizations. Fourth edition. Josey Bass, San Francisco CA.
Posner B, Kouzes J (1988) Development and validation of the leadership practices inventory. Educational Psychological Measurement. 48, 2, 483-496.
inventory - updated. Educational and Psychological Measurement. 53, 1, 191-198. Posner B, Kouzes J (2014) The Leadership Challenge. www.theleadershipchallenge.com (Last accessed: February 9 2016.) Sherman R, Bishop M, Eggenberger T et al (2007) Development of a leadership competency model. Journal of Nursing Administration. 37, 2, 85-94. Supamanee T, Krairiksh M, Singhakhumfu L et al (2011) Preliminary clinical nursing leadership competency model: a qualitative study from Thailand. Nursing and Health Sciences. 13, 4, 433-439.
Posner B, Kouzes J (1993) Psychometric properties of the leadership practices
March 2016 | Volume 22 | Number 10 31
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Evaluation of a nurse leadership development programme Margaret West and colleagues describe the creation of the Nurses Emerging as Leaders programme and analyses its effectiveness Correspondence [email protected] Margaret West is director of system nursing research, Geisinger Health System, Nursing Education Center, Danville, Pennsylvania Lisa Smithgall is vice president of patient care services, and chief nursing officer, Holston Valley Medical Center, Kingsport, Tennessee Greta Rosler is patient care manager, Geisinger Medical Center, Danville, Pennsylvania Erin Winn is human resources administrator, Geisinger Medical Center, Danville, Pennsylvania
Date of submission November 25 2015 Date of acceptance January 26 2016 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines journals.rcni.com/r/ nm-author-guidelines
Abstract The challenge for nursing leaders responsible for workforce planning is to predict the knowledge, skills and abilities required to lead future healthcare delivery systems effectively. Succession planning requires a constant, competitive pool of qualified nursing leader candidates, and retention of those interested in career growth. Formal nursing leadership education in the United States is available through graduate education and professional nursing organisation programmes, such as the Emerging Nurse Leader Institute of the American Organization of Nurse Executives. However, there is also a need for local development programmes tailored to the DEVELOPING, ADVANCING and evaluating nursing leadership competency can improve clinical outcomes for patients and build high-performing nursing teams. Successful nurse leaders must be responsive, demonstrate flexibility, apply the concepts of leadership effectively, and know how to make personal connections. The Nurses Emerging as Leaders (NEL) programme at Geisinger Health System, one of the largest rural health systems in the US, helps to establish and develop these attributes. Many healthcare institutions highlight the lack of leadership skills and preparedness of nurse leaders to meet the challenges of evolving healthcare environments (Bondas 2006). Formal education through master’s programmes can provide an excellent foundation on which to build these skills, but leaders also must meet the specific needs of healthcare institutions. Identifying and preparing nursing leaders for operational and patient care unit management, as well as system leadership, can be challenging, particularly in rural areas with limited human resources.
26 March 2016 | Volume 22 | Number 10
needs of individual organisations. Leaders at Geisinger Health System, one of the largest rural health systems in the US, identified the need for an internal professional development scheme for nurses. In 2013 the Nurses Emerging as Leaders programme was developed to prepare nurse leaders for effective leadership and successful role transition. This article describes the programme and an evaluation of its effectiveness. Keywords leadership, leader development, leadership education, management, workforce planning Before the development of the NEL programme, the identification and preparation of nurses for leadership positions at Geisinger depended on many factors, including individuals’ work experience and educational preparation, level of mentorship and the culture of the working environment. Executive nursing leaders recognised that previous methods were inconsistent and ineffective, and at times resulted in new leaders being unsuccessful. The goal, therefore, was to formalise nursing leadership preparation. Staff in the Geisinger human resources (HR) department analysed future retirement and growth expectations in nursing management positions to predict turnover. Based on average retirement age, results showed turnover expectations of more than 30% for the next ten to 15 years, so, with support from leaders in nursing and HR, a plan was created to develop an internal nursing leadership programme. A development team of HR specialists, and executive and operational nursing leaders from across the health system, created a tailored, flexible NURSING MANAGEMENT
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educational programme to meet succession planning needs at various leadership levels. The aims were to invest in potential nurse leaders and retain them in the organisation, and to develop a more prepared and competitive group of candidates for future nursing leadership opportunities. The programme’s curricular framework is based on a combination of the Geisinger leadership competencies and three of the American Organization of Nurse Executives (AONE) (2011) nursing executive competencies (Table 1). The Geisinger leadership competencies model, developed to ensure continuous improvement in people and processes, provides a baseline of expected skills and behaviours for all leaders. It comprises seven domains, each of which includes a definition and examples of behaviour that demonstrate achievement of the core leadership competency. The domains are: ■■ Inspiring engagement. ■■ Driving results. ■■ Influential leadership. ■■ Promoting teamwork and collaboration. ■■ Leading change and innovation. ■■ Advocating excellence. ■■ Strategic planning and implementation. The AONE nurse executive competencies comprise the following domains: ■■ Communication and relationship building. ■■ Knowledge of the healthcare environment. ■■ Leadership. ■■ Professionalism. ■■ Business skills. Each AONE competency domain includes a list of skills common to nurses in executive practice and applicable to nurse leaders at all levels of a healthcare organisation. The degree of competency is dependent on each individual leader’s position.
Educational structure The NEL programme takes a year to complete. Participants attend one, eight-hour education day every four to six weeks, and this focuses on one of the leadership competencies. The educational content of the sessions includes, but is not limited to, transition into leadership, HR leadership, leading change, influential leadership, finance, quality, strategic planning, and regulatory and professional issues. As well as educational presentations on global and leadership theory, each session includes complementary presentations, delivered by experienced nurse leaders, on the application of theory to nursing and to patient care unit management, and discussions about individuals’ leadership journeys. NURSING MANAGEMENT
Participants are given reading assignments to complete before each NEL session, and attend additional educational programmes. Undertaking these extra learning activities enhances participants’ preparation and supports their leadership competency development. Application of taught theory and competencies is supported through the project component of the programme. Each participant is assigned a mentor and given guidance on identifying and completing a project that uses their newly acquired knowledge and skills. They then share their learning with the rest of the group. The programme is designed to allow time for networking with other participants, and to meet other leaders throughout the healthcare system. Programme participant selection is based on set criteria. For example, a written application describing goals and views on effective leadership must be submitted, with examples of how candidates lead improvements. A formal recommendation from an immediate supervisor confirming high performance in a supervisory role must also be obtained. In addition, a bachelor of science in nursing degree is a minimum educational qualification. Participant numbers are limited to between 16 and 18 a year, which fosters competition among potential nurse leaders, and in general fewer than half the applicants are accepted on to the programme.
Succession planning needs The NEL programme retains the same goals each year but is adapted to meet the succession planning needs of the organisation. Programme ‘focus’ is determined jointly by the development team and the organisation’s nurse leaders. In 2014, the NEL programme focused on nurses, such as team co-ordinators, team leaders or clinic nurse supervisors, who are already in established supervisory roles and were interested in moving to the next level of nursing leadership. However, as the programme progressed, nursing leaders identified the need to develop nurses who wanted to prepare for a first supervisory role. A similar process of turnover analysis, exploration of growth expectations and recruitment efforts was undertaken, which confirmed the need to adapt the programme and offer it to this level of participant to support the organisation’s emerging needs. The adapted programme was rolled out in 2015 and focused on nurses who demonstrated excellent informal leadership and wanted to prepare for a first supervisory opportunity, such as a team co-ordinator or nurse supervisor. Applicants who demonstrated high levels of competence as charge March 2016 | Volume 22 | Number 10 27
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Art & science | management education Table 1
The Geisinger leadership competencies and three of the American Organization of Nurse Executives nurse executive competencies
Geisinger leadership competencies
American Organization of Nurse Executives nurse executive competencies
Communication and relationship building
Knowledge of the healthcare environment
Leadership
Inspiring engagement
■■ Relationship management ■■ Influencing behaviours ■■ Shared decision making ■■ Medical staff relationships
■■ Clinical practice knowledge ■■ Delivery models and work design
■■ Systems thinking ■■ Succession planning ■■ Change management ■■ Personal and professional accountability
Driving results
■■ Medical staff relationships
■■ Healthcare economics
■■ Change management ■■ Personal and professional accountability ■■ Financial management ■■ Human resource management
Influential leadership
■■ Effective communication ■■ Relationship management ■■ Medical staff relationships
■■ Delivery models and work design ■■ Evidence-based practice and outcome measurement
■■ Foundational thinking skills ■■ Personal journey and disciplines ■■ Systems thinking ■■ Succession planning ■■ Change management ■■ Personal and professional accountability
Promoting teamwork and collaboration
■■ Effective communication ■■ Shared decision making ■■ Community involvement ■■ Medical staff relationships ■■ Academic relationships
Leading change and innovation Advocating excellence
■■ Delivery models and work design
■■ Medical staff relationships ■■ Academic relationships
Strategic planning and implementation
Competencies without Geisinger counterpart
■■ Human resource management
■■ Diversity
28 March 2016 | Volume 22 | Number 10
■■ Clinical practice knowledge ■■ Delivery models and work design ■■ Evidence-based practice and outcome measurement ■■ Patient safety ■■ Quality improvement and metrics ■■ Risk management
■■ Evidence-based practice and outcome measurement
■■ Healthcare economics ■■ Healthcare policy ■■ Governance
■■ Advocacy ■■ Strategic management
■■ Utilisation and case management ■■ Career planning ■■ Ethics ■■ Active membership in professional organisations ■■ Marketing ■■ Information management and technology
NURSING MANAGEMENT
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nurses or preceptors, and who were already engaged in shared governance activities, were selected. The programme’s content and project work are adapted to suit the appropriate level of professional development for each individual. Such flexibility also provides opportunities for nurses at various points on the leadership pathway, and creates an internal pool of candidates able to meet the various recruitment needs of the organisation.
Evaluation of content At the end of the NEL programme, participants are emailed a feedback tool comprising open‑ended questions. They are asked to evaluate the course content and its relevance to their leadership development and goals, to define how the learning has affected their leadership style and activities, describe what elements are most and least effective, and suggest topics they think should be included. Participants are also asked to suggest additional professional development topics they might find beneficial at future NEL retreats or reunions for the programme’s graduates. Feedback from the first two groups was positive. Most participants said they appreciated all aspects of the course, and expressed their wish to be invited to future sessions. Many commented that more practical sessions on finance would be useful, as would further learning about difficult conversations and conflict. The nursing leadership team evaluated whether participation affected nurse leaders’ competencies compared with those who had not taken part. The study protocol was reviewed and approved by the Geisinger Health System institutional review board. Two of the questions posed were: ■■ Was there a difference in the competency scores of nurse leaders who completed the NEL programme compared to those who did not take part? ■■ Do nurses who work with these leaders perceive any difference between the two groups? Two leadership inventories were used to assess the nurse leader participants’ change in practice and behaviours: the Leadership Practices Inventory (LPI) (Kouzes and Posner 2003), and the Nurse Manager Skills Inventory (NMSI) (Nurse Manager Leadership Collaborative (NMLC) 2004). Nurse leader participants completed the LPI ‘self’ survey and the NMSI, and staff members completed the LPI ‘observer’ survey. Ten months after the end of the programme, 15 NEL nurse leaders and 15 non-NEL nurse leaders were invited to complete the LPI self survey and the NMSI. Two qualified nurses completed the LPI NURSING MANAGEMENT
observer survey for each NEL nurse leader and for each non-NEL nurse leader, so that a comparison could be made between staff evaluation of the programmes’ participants and non-participants. The Kouzes and Posner theoretical framework (Kouzes and Posner 1998, 2006, 2007, 2013) incorporates five fundamental practices of exemplary leadership, each delineated by statements that provide a guide to desired leadership behaviours: ■■ Challenging the process: searching for opportunities, experimenting and taking risks. ■■ Inspiring a shared vision: envisioning the future and enlisting the support of others. ■■ Enabling others to act: fostering collaboration and strengthening others. ■■ Modeling the way: setting an example and planning small successes. ■■ Encouraging the heart: recognising contributions and celebrating accomplishments. These practices form the basis of Kouzes and Posner’s LPI (2013), which measures charge nurse leadership. This tool was selected because it provides concurrent measurement of nurse leaders’ perceptions of their leadership abilities and staff’s perceptions of their nurse leader’s leadership abilities. The LPI is a 30-item Likert-style scale from 1 (low) to 5 (high), with a range of summed scores from 30 to 150. Kouzes and Posner’s method of test administration consists of matching a self subject with observer subjects. The instruments have been tested for reliability and validity by more than 36,000 multinational subjects and have a reported Cronbach’s alpha range of between .70 and .85 for the self instrument, and .81 and .92 for the observer version (Posner and Kouzes 1988, 1993, 2014).
Nurse manager skills inventory The NMLC Learning Domain Framework (NMLC 2006) is a competency model widely used for nursing leadership development at unit level; unit‑level nurse leaders work as operations managers or team leaders rather than at higher executive levels. To address the need for leadership development, AONE, the Association of periOperative Registered Nurses, and the American Association of Critical‑Care Nurses, collaborated to develop the framework to identify competency domains required by current and future nurse leaders. In addition, the NMSI (NMLC 2004) outlines the main skills needed by nurse managers in each competency domain area, and can be used to develop charge nurses, team leaders and emerging leaders. It also allows nurses to use Benner’s (1985) March 2016 | Volume 22 | Number 10 29
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Art & science | management xxx education Figure 1 Comparison scores between leaders who undertook the Nurses Emerging as Leaders programme and those who did not 300 -
Non-NEL leader NEL leader
250 -
Results
200 150 100 50 0
LPI Observer
LPI Self
NMSI
NEL = Nurses Emerging as Leaders LPI = Leadership Practices Inventory NMSI = Nurse Manager Skills Inventory five novice-to-expert stages of skill acquisition. The three domains of the NMLC framework also provide a useful structure for focusing development activities on growing nurse leaders at unit level: ■■ Domain 1 is ‘the leader within: creating the leader in yourself’. ■■ Domain 2 is ‘the art of leadership: leading people’. ■■ Domain 3 is ‘the science of leadership: managing the business’. Successful nurse managers must gain some level of expertise in all three domains. Often nurse leaders have no formal leadership education before taking on their first leadership role, and are generally promoted based on clinical expertise and effectiveness. Taking on a nursing leadership role reduces clinical experts to novices, and progression towards, and attainment of, expert level practice is not guaranteed. Benner’s (1985) stages of skill acquisition provide a framework to support nursing leadership development with theoretical knowledge and practical application. The movement from novice to expert nursing leader is characterised by the transition from leaders who function primarily with rulegoverned behaviours, to those who demonstrate intuitive, contextually determinate behaviours (Altmann 2007). Competency models also provide frameworks for the design and implementation of leadership 30 March 2016 | Volume 22 | Number 10
development programmes, and there is a range that can be explored (Sherman et al 2007, Calhoun et al 2008, Huston 2008, Supamanee et al 2011). However, the Geisinger NEL is based on Kouzes and Posner’s competency models, the NMLC learning domain framework, and Benner’s novice-to-expert framework.
The results of the inventory surveys will be used to develop NEL programme content, and will be compared with participants’ feedback to improve the programme’s relevancy to leaders’ learning needs. To evaluate the effectiveness of the NEL programme, each of the items in the LPI observer, LPI self and NMSI surveys were compared between the NEL participants and staff, and non-NEL participants and staff. The data show that NEL nursing leaders received higher scores in the LPI self and the LPI observer surveys (Figure 1). The LPI self and LPI observer questions that showed the greatest improvement among NEL participants are shown in Box 1. NEL programme participants also showed improvement in the NMSI survey subcategories (Figure 2). The NMSI questions that showed the greatest improvement among NEL participants are listed in Box 2: nine were from the ‘managing the Box 1 Leadership Practices Inventory questions showing the greatest improvement among programme participants Self questions Q8 I challenge people to try out new and innovative ways to do their work Q12 I appeal to others to share an exciting dream of the future Q16 I ask for feedback on how my actions affect other people’s performance Q22 I paint the big picture of what we aspire to accomplish Q28 I experiment and take risks, even when there is a chance of failure Observer questions Q12 Appeals to others to share an exciting dream of the future Q23 Makes certain that we set achievable goals, make concrete plans, and establish measurable milestones for the projects and programmes that we work on Q26 Is clear about his/her philosophy of leadership Q27 Speaks with genuine conviction about the higher meaning and purpose of our work NURSING MANAGEMENT
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business’ section and two were from the ‘creating the leader in yourself’ section.
Conclusion Delivering optimal patient care and outcomes in ever-changing healthcare environments depends on organisations’ ability to support successful transition of individuals into nursing leadership roles. The NEL programme improves succession planning by developing leaders from within Geisinger’s nursing teams, who are then well prepared for promotion when leadership positions become available. Having knowledgeable nursing leaders with the skills to undertake their role successfully will increase levels of personal satisfaction and morale, which also increases the likelihood of retention. Identifying mentors for new leaders is a crucial supplement to education, and provides Figure 2 Subcategories of Nurse Manager Skills Inventory survey 140 -
Non-NEL leader NEL leader
120 100 80 60 40 20 0 Managing
Leading
Creating
NEL = Nurses Emerging as Leaders
Box 2 Nurse Manager Skills Inventory questions showing the greatest improvement among programme participants ■■ Understanding of healthcare economics and healthcare public policy as it applies to the delivery of patient care ■■ Keeping commitments to oneself ■■ Creating and managing a budget ■■ Ability to alter roles based on changing department and healthcare environment needs ■■ Expense forecasting ■■ Identification of important skills and attributes for each role ■■ Diversity as a vehicle to wholeness ■■ Monitoring a budget ■■ Creating a budget ■■ Interpreting financial information ■■ Department-based budgeting opportunities for role modeling, situational sharing and discussion, and coaching and support, thus supporting effective transition to operational unit leadership roles. In addition, mentoring promotes continuous leadership development and competency education, real-time problem solving, and development of critical thinking. Further evaluation of the NEL programme is required to ensure the content remains current, and that individuals’ goals and the organisation’s succession planning needs are met. Growing nurse leaders is a long-term project that requires planning and action. The most significant contribution leaders can make to the future of nursing is to develop their successors. Emerging leaders will eventually replace them and continue the vital work being done to improve nursing environments and, most importantly, patient outcomes.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
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