Art & science | The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
PROCESSES TO ENGAGE AND MOTIVATE STAFF Amanda Henderson and colleagues describe a project that improved team relationships and the work environment by using transformational leadership to address poor working practices Correspondence [email protected]. gov.au Amanda Henderson is nursing director (education) Sue Schoonbeek is nurse educator Anthony Auditore is nurse manager All at Princess Alexandra Hospital, Woolloongabba, Brisbane, Queensland, Australia Date of submission September 18 2013 Date of acceptance October 9 2013 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nm.rcnpublishing.com
Abstract Nursing has a history of poor workplace contexts in which the focus has been on performing and completing tasks, rather than engaging fully with patients. Further, nursing practice is increasingly driven by bureaucratic demands and service requirements, which can result in neglect of the workplace needs of staff. This article describes how a nurse unit manager changed a poor working environment in one surgical unit by using transformational leadership techniques to address procedural employment practices and poor team relationships. With support from nurse educators in the nursing practice development unit, clinical staff engaged in a series of activities that improved their work relationships, as well as professional and clinical development. Keywords Behaviour, positive work environment, transformational leadership EFFECTIVE ORGANISATIONAL learning is essential if practice is to remain up to date, and it is a fundamental element of many best nursing practice frameworks, such as the Magnet Recognition Program, which recognises organisations for high quality patient care, nursing excellence and innovations in professional nursing practice (American Nurses Credentialing Center 2013), as well as practice and clinical development units and structured frameworks for implementing evidence in practice.
18 December 2013 | Volume 20 | Number 8
Common to these frameworks is a culture of democracy and innovation, with an emphasis on transformational leadership and support for staff to explore good practice and initiate change (Henderson and Winch 2008). Desired characteristics of the constructive workplace environments that incorporate the frameworks cited above include positive relationships, team building, recognition of achievements and being heard (Henderson et al 2010, Schalk et al 2010). However, the organisation of nursing work has often not been conducive to developing such characteristics. The traditions that have contributed to this have been documented extensively and include: The organisation of nursing work, so that nurses interact with patients to perform specific tasks, rather than engage with them to perform a broad range of activities to support patients’ overall wellbeing. This way of working does not support understanding patients as individuals and, ultimately, limits nurses’ job satisfaction, as they perform repetitive tasks with minimal understanding of patients (Menzies 1970). An emphasis on getting the job done, that is, focusing on completing tasks, so that work appears to be complete and the environment organised. Nursing work was focused on the more visible tasks (Melia 1987, Walsh and Ford 1994), and it was largely these that were deemed the most important aspects of healthcare provision (Winch and Henderson 2013). Nursing work is increasingly driven by managerial and bureaucratic demands, including audits, throughputs and incidence rates. Nurse NURSING MANAGEMENT
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Art & science | leadership unit managers (NUMs) have greater responsibilities to improve efficiencies and maintain high quality patient care, which is often achieved by increasing staff focus on service requirements. However, such an approach often neglects the workplace needs of the staff. Hutchinson et al (2006) draw on the notion of disciplinary power, as explained by Foucault (1977), to describe how these imperatives become pervasive legitimating devices that further curtail positive nursing influences. The combination of these factors is not conducive to delivering optimum nursing practice. Some approaches suggest better ways of ensuring patients are at the centre of care, for example through primary nursing (Pontin 1999). However, patient information that is regularly and routinely documented in care delivery is largely biomedical, and this does not promote the development of therapeutic relationships (Henderson 1994). The Francis (2013) report comprehensively identifies and describes how these challenges manifest in care provision. Effective leadership is important to curtail problems and leaders, in particular, need to focus on high quality care provision rather than administrative targets. When leadership is ineffective and targets become the focus, staff do not feel a sense of purpose or worth, are less likely to engage in work, and are more likely to provide essential rather than optimum care. If this is the situation in a workplace, constructive relationships need to be developed to improve the environment and, ultimately, increase staff satisfaction. Initiating constructive relationships starts with the local leader, who can be the ward manager, ward sister or NUM, who has the relevant influence and jurisdiction (Fenton and Phillips 2013). They are instrumental in any change processes (Duffield et al 2009). While the importance of constructive relationships is not disputed, and the leadership traits required to sustain high quality care are frequently discussed in the literature, less is known about leadership practices instrumental in reducing poor practice and increasing quality practice (Cummings et al 2010). A transformational leader can motivate and improve morale, encourage best practice by inspiring others, listen and have confidence to challenge bureaucratic imperatives, and make changes when necessary (Heuston and Wolf 2011, Fenton and Phillips 2013). By adopting transformation principles, an NUM can motivate and engage staff to improve practice. This article evaluates a project that resulted in improving nursing practice on one unit and 20 December 2013 | Volume 20 | Number 8
increasing quality initiatives after the NUM adopted transformational leadership behaviours. The aim of the project was for staff to be inclusive of students and new staff members, to help them integrate in the unit and learn to perform specialist skills, as well as raise the quality of standards of practice.
The process Background In November 2010, the NUM of a specialist surgical unit recognised that staff performance was procedural; they were meeting their minimum requirements but not engaging in collaborative interactions with patients, students and colleagues. This became evident to the NUM through regular formal feedback collected from students and patients. The NUM sought assistance from nurse educators in the district’s nursing practice development unit (NPDU) about how to use transformational leadership to motivate staff to engage with others in the clinical area. This form of leadership focuses on feedback, learning and improving quality, rather than on simply performing duties. Initiating such change required considerable energy because minimum practice had become the norm. It has been suggested that possible reasons for this could be nurses becoming complacent, feeling powerless or even denying that practice can be improved (Leah and Fenton 2012). The NPDU is an advisory and support unit with six nurse educators who help nurses in clinical areas create optimum working practices through formal and informal staff development opportunities. The unit manager wanted advice on how to challenge traditional models about ‘how things are done’, to initiate changes. First, with help from NPDU staff, the authors made a ‘progressive plan’, consistent with transformational leadership, to bring about the desired behaviours: ■■ Create a vision for staff to follow. ■■ Challenge existing behaviours, particularly negative interactions. ■■ Encourage staff to contribute to decisions. ■■ Support access to clinical knowledge and individual skills development. ■■ Sustain efforts through reward and recognition of desired behaviours (Heuston and Wolf 2011, Schoonbeek and Henderson 2011). Create a vision The third author (AA) met with staff to share his expectations of staff engagement and encourage sharing of experiences to improve care delivery. Staff were encouraged to share thoughts and ideas during extended time in unit meetings, time that was not allocated for pre-determined NURSING MANAGEMENT
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tasks. The NUM listened and responded to staff who requested more input in decision making. These staff were subsequently provided with opportunities and accompanying responsibilities. They were also encouraged to support their peers when they voiced concerns, which was important for empowering the team (Kinnair 2013). Challenge existing behaviours Nurse educators in the NPDU met with the NUM and clinical nurses (local leaders) and led unit activities to guide the desired behaviour changes. Staff were coached in how to effectively stop and listen to others and acknowledge their concerns. The clinical team was encouraged to be aware of others in the unit and offer assistance when necessary; for example, staff practised ‘shielding’ other staff, that is, strategically positioning themselves beside another staff member if they thought that their colleague was being threatened (Schoonbeek and Henderson 2011). As the desired behaviours increased, staff stopped what they were doing to move to the assistance of other staff members, and team cohesion and respect gradually increased. Encourage staff to contribute Nurses’ knowledge base and capacity to contribute to decision making were enhanced by bringing more interactive education to the bedside. This was achieved by employing extra staff on designated days and using a vacant four-bed bay on the ward to demonstrate and role play everyday skills, from intravenous therapy management to complex wound dressings. Staff were relieved by colleagues for short periods (four hours) on designated study days (two or three a year), to free up time for teaching and demonstration. Graduate nurses were provided with additional time as necessary. Enabling learning close to the clinical work area resulted in clinicians bringing timely and relevant questions about their practice to the clinical sessions. Clinical expertise was improved through one-to-one guidance and small group teaching of a series of procedural skills. Staff proficiency was developed through gradual progression from simple tasks to more complex skills. As staff competency improved, their skills were assessed to determine their ability to teach less experienced colleagues. Those who demonstrated higher levels of competence were then supported to teach and assess the clinical performance of less experienced colleagues. All staff were awarded certificates after they had completed the relevant development activities. NURSING MANAGEMENT
Sustaining new behaviours A programme of unit activities, led by a nurse educator from the NPDU, focused on improving team behaviours. Sessions lasted between 30 and 45 minutes, and were conducted when the clinical area was not too busy. Following the sessions, the NUM role modelled preferred behaviours, which were discussed. This included ensuring AA’s accessibility and being readily available if staff needed assistance or clarification on clinical or administrative matters. The NUM would also routinely circulate around the unit and confirm with individual members of the team during the shift that they were effectively managing patient care. This intensive series of interactive activities was conducted every two to three weeks for between five and six months. Sessions were repeated on the same day to maximise attendance and minimise disruption to care provision. Activities involved helping staff explore and practise how to challenge members of the team who exhibit poor behaviours. Staff also practised giving feedback to colleagues and having difficult conversations in a non-threatening environment away from the clinical unit. The NUM, collectively with unit staff, also considered innovative and creative ways to recognise and reward positive performance. Reward and recognition were viewed as important to encourage the continuation of the desired behaviours practised at the sessions (Schoonbeek and Henderson 2011). The input of the NUM was important. They role modelled desired behaviours, such as accessibility and helpfulness, and praised staff when they did the same. A nurse educator from the NPDU visited the unit weekly to coach the NUM in effective reward and recognition and, in particular, the importance of rewards being specific so that poor behaviour was not rewarded. The nurse educator also added value to the activities by providing further rewards, such as tokens for exemplary behaviour. Consequently, nursing practice exceeded the minimum regulatory healthcare standards, but staff performance improved, increasing morale and motivation.
Evaluation The outcomes of the project were evaluated by analysing daily notes collected by the nurse educator and another NPDU staff member, who recorded staff behaviours and interactions in the clinical unit. The notes comprised feedback from senior clinical staff, and informal observations of the interactions of staff in the unit. Discussion with senior staff members in the unit provided feedback about their perceptions of December 2013 | Volume 20 | Number 8 21
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Art & science | leadership changes in the unit. Staff were also surveyed at the start of the project and 12 months later. The survey included questions about staff perception of support and about their unit’s culture. The notes and staff survey responses indicated that the series of practice reforms had been successful, and that the changes were sustained six months after completion of the suite of activities engaged in by staff. Ethics approval The evaluation of the initiative was granted ethics approval by the hospital human research ethics committee. Nurses agreed to provide their demographic details and responses to the Support Instrument for Nurses Facilitating the Learning of Others (Sinflo) (Henderson et al 2012) and Clinical Learning Organisational Culture Survey (Clocs) (Henderson et al 2010). No personal details or identifying factors were collected. Diarised notes Following the start of the project, every two to three weeks NPDU staff discussed the changes that local leaders had observed. The changes and what the leaders described as ‘local successes’ were recorded as field notes by NPDU staff. The notes were not schematically analysed because feedback was largely consistent with the project aims. The changes noted were: ■■ Staff engaged less in gossip and other negative behaviours. ■■ Staff actively sought the assistance of others if they were not sure about a clinical procedure, and would readily approach the NUM about any concerns, rather than remain uncertain about what was needed. ■■ Staff were responsive to others’ concerns and readily responded to requests for help, instead of ignoring or blocking colleagues who approached them. ■■ Staff were open in their communication and proactively engaged in decision making, which replaced the complaining and whinging that had occurred previously. ■■ Staff appeared to be confident in determining their competence, demonstrated by an increased willingness to seek help when they felt a situation was particularly challenging. ■■ Staff enjoyed sharing their achievements, which suggested that they were proud of their work and the unit. Staff survey All nurses in the clinical unit were asked to complete the survey before the activities began and repeat data were collected a year later, six months after completion of the sessions designed to help 22 December 2013 | Volume 20 | Number 8
staff create and sustain healthy workplaces. Paper surveys were distributed, which were completed at work. The survey included the Sinflo (Henderson et al 2012), a validated tool comprising 18 items that measure the following factors: ■■ Teamwork: staff consider they have the support of the team. ■■ Communication: staff are kept informed about unit situations and learning requirements. ■■ Recognition: staff are acknowledged by their leaders. ■■ Preparation: staff are prepared for their teaching role. ■■ Workload: staff workloads recognise their teaching responsibilities (Henderson et al 2012). It also included the Clocs (Henderson et al 2010) validated tool, comprising 28 items that measure five attributes recognised as important for quality learning environments: dissatisfaction, recognition, affiliation, accomplishment and influence. Staff responded to all 46 items using a Likert scale of one to five, where one indicated ‘strongly disagree’ and five ‘strongly agree’. Survey response Forty nine nurses completed the survey. There are more on the roster, but some were on extended leave. Twenty seven (55 per cent) completed the first survey before the project began and 24 (49 per cent) completed the second, follow-up survey. The roster comprises nearly all registered nurses (RNs) with five endorsed enrolled nurses, who are licensed nurses who must practise under RN supervision. It was not necessarily the same nurses who completed the pre- and post‑project surveys. Statistics Data were analysed using Stata 10 (Statacorp, Texas), a PC-based software statistical package. Descriptive statistics were used to examine survey respondents’ characteristics, and survey data were checked for anomalies in recording. Scoring for negatively worded questions were reversed. T-tests were used to compare pre- and post-project data for each of the subscales of the Sinflo and Clocs.
Findings All results for all subscales on the Sinflo and Clocs showed improvement, except for Influence. A number of these were statistically significant. Facilitating others’ learning Of the five subscales on the Sinflo, two – Acknowledgement and Teamwork – reported statistically significant differences (Table 1). These two subscales were the lowest, indicating a negative perception at the start of the NURSING MANAGEMENT
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Table 1 Results for Support Instrument for Nurses Facilitating the Learning of Others (Sinflo) Sinflo
Workload
Acknowledgement
Teamwork
Communication
Preparation
Pre-project, n=27
2.9
2.9
3.2
3.8
3.6
Post-project, n=24
2.9
3.4
3.6
3.9
3.9
Statistically significant
0.9
Yes P=0.04
Yes P=0.04
0.4
0.07
Accomplishment
Influence
Table 2 Results for Clinical Learning Organisational Culture Survey (Clocs) Clocs
Dissatisfaction score reversed
Recognition
Affiliation
Pre-project, n=27
3.09
3.60
4.08
4.01
3.00
Post-project, n=24
3.50
3.90
4.25
4.09
2.90*
Statistically significant
Yes 0.02
Yes 0.04
0.08
0.30.
0.08
* Score indicates a negative trend, however the subscale for influence has been reported as lacking clarity and is therefore not a good indicator
project. Unfortunately, staff perception of workload did not change across the time period; the NUM was unable to control this element. The two other subscales, Communication and Preparation, were not as low at the start of the project and the increase in these was not statistically significant. Clinical learning organisational culture Two of the five subscales on the Clocs were statistically significant (Table 2). Specifically, staff indicated less dissatisfaction and more recognition for their work. While two of the other subscales, Affiliation and Accomplishment, indicate trends in the desired direction, these results were not significant.
Discussion The findings from diarised notes and the surveys indicate that workplace behaviours can be modified when NUMs drive and model the change process. The particular changes in behaviour could be summarised as staff: ■■ Engaging less in gossiping and other negative behaviours. ■■ Seeking assistance from colleagues, who were happy to provide feedback. ■■ Replacing complaining with proactive communication. NURSING MANAGEMENT
Evidence of these behaviour changes could arguably be seen in the significant changes in staff perception of Acknowledgement and Teamwork (subscales in the Sinflo). The scores from analysis of the Sinflo pre- and 12 months after the NUM-initiated activities suggest that staff behaviour changed, so they were receptive, willing to collaborate, and actively engaged in giving feedback. Practices that increased a willingness to work and co-operate with one another may have affected the Dissatisfaction subscale, which was significantly reduced (Table 2). Influence did not alter during the project, which is a concern; however, the poor result on Clocs might be due to the difficulty in differentiating and clarifying the concept itself (Henderson et al 2010). Of particular interest is the Recognition subscale (Table 2); in other words, nurses considered that their work was more acknowledged, with higher scores in the Sinflo and Clocs surveys. This is perhaps attributable to the reward and recognition programme, which was important in motivating staff to participate and, subsequently, sustain their altered behaviours. The effectiveness of the reward and recognition programme was, arguably, its authenticity and its timeliness; it advocated for realistic and honest December 2013 | Volume 20 | Number 8 23
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Art & science | leadership feedback and appraisal, and was delivered in a short time, often during the same shift. Of significance was that the NUM managed these changes using existing resources and with support from nurse educators in the NPDU. Limitations The unit-based practices designed to encourage staff to engage positively in helping others appear to have been successful. However, not all staff were able to attend every session because of clinical workload, but those who were able to do so shared as much of their learning as possible. At the time these sessions were conducted, a number of clinical nurses were in temporary positions and, although the NUM encouraged them to feel comfortable about asserting themselves, some were less confident than the permanent staff about making significant changes because of their temporary status.
Conclusion Transformational leadership is important for high quality care delivery, and behaviours that nurse leaders inspire, role model and reinforce are instrumental in creating work practices that deliver optimum care. This is possible when NUMs initiate processes that enable staff to feel greater confidence about discussing and making changes in the workplace. This initiative shows that using rewards in everyday practice can be powerful in shifting perceptions about the value of high standards, teamwork and recognition of work. Values and attitudes commensurate with excellence in care can be embedded through responsive behavioural changes.
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Conflict of interest None declared
References American Nurses Credentialing Center (2013) Magnet Recognition Program Overview. www.nursecredentialing.org/magnet/ programoverview (Last accessed: November 11 2013.) Cummings G, MacGregor T, Davey M et al (2010) Leadership styles and outcomes patterns for the nursing workforce and work environment: a systematic review. International Journal of Nursing Studies. 47, 3, 363-385. Duffield C, Roche M, O’Brien-Pallas L et al (2009) Staff satisfaction and retention and the role of the nursing unit manager. Collegian. 16, 1, 11-17. Fenton K, Phillips N (2013) Developing skills in clinical leadership for ward sisters. Nursing Times. 109, 9, 12-15. Foucault M (1977) Discipline and Punish. Random House, Toronto ON.
Francis R (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry Report. www.midstaffspublicinquiry.com/report (Last accessed: September 18 2013).
Heuston M, Wolf G (2011) Transformational leadership skills of successful nurse managers. Journal of Nursing Administration. 41, 6, 248-251.
Henderson A (1994) Power and knowledge in nursing practice: the contribution of Foucault. Journal of Advanced Nursing. 20, 5, 935-939.
Hutchinson M, Vickers M, Jackson D et al (2006) Workplace bullying in nursing: towards a more critical organisational perspective. Nursing Inquiry. 13, 2, 118-126.
Henderson A, Creedy D, Boorman R et al (2010) Development and psychometric testing of the Clinical Learning Organisational Culture Survey (Clocs). Nurse Education Today. 30, 7, 598-602. Henderson A, Eaton E, Burmeister L (2012) Development and preliminary validation of a tool to measure nurses’ support for facilitating the learning of others. International Journal of Nursing Studies. 49, 8, 1013-1016. Henderson A, Winch S (2008) Managing the clinical setting for best nursing practice: a brief overview of contemporary initiatives. Journal of Nursing Management. 16, 1, 92-95.
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Kinnair D (2013) Staff need to speak out freely. Nursing Management. 19, 10, 3. Leah V, Fenton K (2012) Give sisters the freedom to be ward leaders and innovators. Nursing Times. 108, 16, 7. Melia K (1987) Learning and Working: The Occupational Socialisation of Nurses. Tavistock, London. Menzies I (1970) The Functioning of Social Systems as a Defence against Anxiety. Tavistock, London.
Pontin D (1999) Primary nursing: a mode of care or a philosophy of nursing. Journal of Advanced Nursing. 29, 3, 584-591. Schalk D, Bijl M, Halfens R et al (2010) Interventions aimed at improving the nursing work environment: a systematic review. Implementation Science. 5, 34. Schoonbeek S, Henderson A (2011) The journey of building a learning culture. Journal of Continuing Education in Nursing. 42, 1, 43-48. Walsh M, Ford P (1994) New Rituals for Old: Nursing through the Looking Glass. Butterworth-Heinemann, Oxford. Winch S, Henderson A (2013) The growth of ideas and theory in nursing. In Daly J et al (eds) Contexts of Nursing. Fourth edition. Elsevier, Marrickville NSW.
NURSING MANAGEMENT
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JOSEPHINE G PATERSON
PROCESSES TO ENGAGE AND MOTIVATE STAFF Amanda Henderson and colleagues describe a project that improved team relationships and the work environment by using transformational leadership to address poor working practices Correspondence [email protected]. gov.au Amanda Henderson is nursing director (education) Sue Schoonbeek is nurse educator Anthony Auditore is nurse manager All at Princess Alexandra Hospital, Woolloongabba, Brisbane, Queensland, Australia Date of submission September 18 2013 Date of acceptance October 9 2013 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nm.rcnpublishing.com
Abstract Nursing has a history of poor workplace contexts in which the focus has been on performing and completing tasks, rather than engaging fully with patients. Further, nursing practice is increasingly driven by bureaucratic demands and service requirements, which can result in neglect of the workplace needs of staff. This article describes how a nurse unit manager changed a poor working environment in one surgical unit by using transformational leadership techniques to address procedural employment practices and poor team relationships. With support from nurse educators in the nursing practice development unit, clinical staff engaged in a series of activities that improved their work relationships, as well as professional and clinical development. Keywords Behaviour, positive work environment, transformational leadership EFFECTIVE ORGANISATIONAL learning is essential if practice is to remain up to date, and it is a fundamental element of many best nursing practice frameworks, such as the Magnet Recognition Program, which recognises organisations for high quality patient care, nursing excellence and innovations in professional nursing practice (American Nurses Credentialing Center 2013), as well as practice and clinical development units and structured frameworks for implementing evidence in practice.
18 December 2013 | Volume 20 | Number 8
Common to these frameworks is a culture of democracy and innovation, with an emphasis on transformational leadership and support for staff to explore good practice and initiate change (Henderson and Winch 2008). Desired characteristics of the constructive workplace environments that incorporate the frameworks cited above include positive relationships, team building, recognition of achievements and being heard (Henderson et al 2010, Schalk et al 2010). However, the organisation of nursing work has often not been conducive to developing such characteristics. The traditions that have contributed to this have been documented extensively and include: The organisation of nursing work, so that nurses interact with patients to perform specific tasks, rather than engage with them to perform a broad range of activities to support patients’ overall wellbeing. This way of working does not support understanding patients as individuals and, ultimately, limits nurses’ job satisfaction, as they perform repetitive tasks with minimal understanding of patients (Menzies 1970). An emphasis on getting the job done, that is, focusing on completing tasks, so that work appears to be complete and the environment organised. Nursing work was focused on the more visible tasks (Melia 1987, Walsh and Ford 1994), and it was largely these that were deemed the most important aspects of healthcare provision (Winch and Henderson 2013). Nursing work is increasingly driven by managerial and bureaucratic demands, including audits, throughputs and incidence rates. Nurse NURSING MANAGEMENT
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Art & science | leadership unit managers (NUMs) have greater responsibilities to improve efficiencies and maintain high quality patient care, which is often achieved by increasing staff focus on service requirements. However, such an approach often neglects the workplace needs of the staff. Hutchinson et al (2006) draw on the notion of disciplinary power, as explained by Foucault (1977), to describe how these imperatives become pervasive legitimating devices that further curtail positive nursing influences. The combination of these factors is not conducive to delivering optimum nursing practice. Some approaches suggest better ways of ensuring patients are at the centre of care, for example through primary nursing (Pontin 1999). However, patient information that is regularly and routinely documented in care delivery is largely biomedical, and this does not promote the development of therapeutic relationships (Henderson 1994). The Francis (2013) report comprehensively identifies and describes how these challenges manifest in care provision. Effective leadership is important to curtail problems and leaders, in particular, need to focus on high quality care provision rather than administrative targets. When leadership is ineffective and targets become the focus, staff do not feel a sense of purpose or worth, are less likely to engage in work, and are more likely to provide essential rather than optimum care. If this is the situation in a workplace, constructive relationships need to be developed to improve the environment and, ultimately, increase staff satisfaction. Initiating constructive relationships starts with the local leader, who can be the ward manager, ward sister or NUM, who has the relevant influence and jurisdiction (Fenton and Phillips 2013). They are instrumental in any change processes (Duffield et al 2009). While the importance of constructive relationships is not disputed, and the leadership traits required to sustain high quality care are frequently discussed in the literature, less is known about leadership practices instrumental in reducing poor practice and increasing quality practice (Cummings et al 2010). A transformational leader can motivate and improve morale, encourage best practice by inspiring others, listen and have confidence to challenge bureaucratic imperatives, and make changes when necessary (Heuston and Wolf 2011, Fenton and Phillips 2013). By adopting transformation principles, an NUM can motivate and engage staff to improve practice. This article evaluates a project that resulted in improving nursing practice on one unit and 20 December 2013 | Volume 20 | Number 8
increasing quality initiatives after the NUM adopted transformational leadership behaviours. The aim of the project was for staff to be inclusive of students and new staff members, to help them integrate in the unit and learn to perform specialist skills, as well as raise the quality of standards of practice.
The process Background In November 2010, the NUM of a specialist surgical unit recognised that staff performance was procedural; they were meeting their minimum requirements but not engaging in collaborative interactions with patients, students and colleagues. This became evident to the NUM through regular formal feedback collected from students and patients. The NUM sought assistance from nurse educators in the district’s nursing practice development unit (NPDU) about how to use transformational leadership to motivate staff to engage with others in the clinical area. This form of leadership focuses on feedback, learning and improving quality, rather than on simply performing duties. Initiating such change required considerable energy because minimum practice had become the norm. It has been suggested that possible reasons for this could be nurses becoming complacent, feeling powerless or even denying that practice can be improved (Leah and Fenton 2012). The NPDU is an advisory and support unit with six nurse educators who help nurses in clinical areas create optimum working practices through formal and informal staff development opportunities. The unit manager wanted advice on how to challenge traditional models about ‘how things are done’, to initiate changes. First, with help from NPDU staff, the authors made a ‘progressive plan’, consistent with transformational leadership, to bring about the desired behaviours: ■■ Create a vision for staff to follow. ■■ Challenge existing behaviours, particularly negative interactions. ■■ Encourage staff to contribute to decisions. ■■ Support access to clinical knowledge and individual skills development. ■■ Sustain efforts through reward and recognition of desired behaviours (Heuston and Wolf 2011, Schoonbeek and Henderson 2011). Create a vision The third author (AA) met with staff to share his expectations of staff engagement and encourage sharing of experiences to improve care delivery. Staff were encouraged to share thoughts and ideas during extended time in unit meetings, time that was not allocated for pre-determined NURSING MANAGEMENT
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tasks. The NUM listened and responded to staff who requested more input in decision making. These staff were subsequently provided with opportunities and accompanying responsibilities. They were also encouraged to support their peers when they voiced concerns, which was important for empowering the team (Kinnair 2013). Challenge existing behaviours Nurse educators in the NPDU met with the NUM and clinical nurses (local leaders) and led unit activities to guide the desired behaviour changes. Staff were coached in how to effectively stop and listen to others and acknowledge their concerns. The clinical team was encouraged to be aware of others in the unit and offer assistance when necessary; for example, staff practised ‘shielding’ other staff, that is, strategically positioning themselves beside another staff member if they thought that their colleague was being threatened (Schoonbeek and Henderson 2011). As the desired behaviours increased, staff stopped what they were doing to move to the assistance of other staff members, and team cohesion and respect gradually increased. Encourage staff to contribute Nurses’ knowledge base and capacity to contribute to decision making were enhanced by bringing more interactive education to the bedside. This was achieved by employing extra staff on designated days and using a vacant four-bed bay on the ward to demonstrate and role play everyday skills, from intravenous therapy management to complex wound dressings. Staff were relieved by colleagues for short periods (four hours) on designated study days (two or three a year), to free up time for teaching and demonstration. Graduate nurses were provided with additional time as necessary. Enabling learning close to the clinical work area resulted in clinicians bringing timely and relevant questions about their practice to the clinical sessions. Clinical expertise was improved through one-to-one guidance and small group teaching of a series of procedural skills. Staff proficiency was developed through gradual progression from simple tasks to more complex skills. As staff competency improved, their skills were assessed to determine their ability to teach less experienced colleagues. Those who demonstrated higher levels of competence were then supported to teach and assess the clinical performance of less experienced colleagues. All staff were awarded certificates after they had completed the relevant development activities. NURSING MANAGEMENT
Sustaining new behaviours A programme of unit activities, led by a nurse educator from the NPDU, focused on improving team behaviours. Sessions lasted between 30 and 45 minutes, and were conducted when the clinical area was not too busy. Following the sessions, the NUM role modelled preferred behaviours, which were discussed. This included ensuring AA’s accessibility and being readily available if staff needed assistance or clarification on clinical or administrative matters. The NUM would also routinely circulate around the unit and confirm with individual members of the team during the shift that they were effectively managing patient care. This intensive series of interactive activities was conducted every two to three weeks for between five and six months. Sessions were repeated on the same day to maximise attendance and minimise disruption to care provision. Activities involved helping staff explore and practise how to challenge members of the team who exhibit poor behaviours. Staff also practised giving feedback to colleagues and having difficult conversations in a non-threatening environment away from the clinical unit. The NUM, collectively with unit staff, also considered innovative and creative ways to recognise and reward positive performance. Reward and recognition were viewed as important to encourage the continuation of the desired behaviours practised at the sessions (Schoonbeek and Henderson 2011). The input of the NUM was important. They role modelled desired behaviours, such as accessibility and helpfulness, and praised staff when they did the same. A nurse educator from the NPDU visited the unit weekly to coach the NUM in effective reward and recognition and, in particular, the importance of rewards being specific so that poor behaviour was not rewarded. The nurse educator also added value to the activities by providing further rewards, such as tokens for exemplary behaviour. Consequently, nursing practice exceeded the minimum regulatory healthcare standards, but staff performance improved, increasing morale and motivation.
Evaluation The outcomes of the project were evaluated by analysing daily notes collected by the nurse educator and another NPDU staff member, who recorded staff behaviours and interactions in the clinical unit. The notes comprised feedback from senior clinical staff, and informal observations of the interactions of staff in the unit. Discussion with senior staff members in the unit provided feedback about their perceptions of December 2013 | Volume 20 | Number 8 21
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Art & science | leadership changes in the unit. Staff were also surveyed at the start of the project and 12 months later. The survey included questions about staff perception of support and about their unit’s culture. The notes and staff survey responses indicated that the series of practice reforms had been successful, and that the changes were sustained six months after completion of the suite of activities engaged in by staff. Ethics approval The evaluation of the initiative was granted ethics approval by the hospital human research ethics committee. Nurses agreed to provide their demographic details and responses to the Support Instrument for Nurses Facilitating the Learning of Others (Sinflo) (Henderson et al 2012) and Clinical Learning Organisational Culture Survey (Clocs) (Henderson et al 2010). No personal details or identifying factors were collected. Diarised notes Following the start of the project, every two to three weeks NPDU staff discussed the changes that local leaders had observed. The changes and what the leaders described as ‘local successes’ were recorded as field notes by NPDU staff. The notes were not schematically analysed because feedback was largely consistent with the project aims. The changes noted were: ■■ Staff engaged less in gossip and other negative behaviours. ■■ Staff actively sought the assistance of others if they were not sure about a clinical procedure, and would readily approach the NUM about any concerns, rather than remain uncertain about what was needed. ■■ Staff were responsive to others’ concerns and readily responded to requests for help, instead of ignoring or blocking colleagues who approached them. ■■ Staff were open in their communication and proactively engaged in decision making, which replaced the complaining and whinging that had occurred previously. ■■ Staff appeared to be confident in determining their competence, demonstrated by an increased willingness to seek help when they felt a situation was particularly challenging. ■■ Staff enjoyed sharing their achievements, which suggested that they were proud of their work and the unit. Staff survey All nurses in the clinical unit were asked to complete the survey before the activities began and repeat data were collected a year later, six months after completion of the sessions designed to help 22 December 2013 | Volume 20 | Number 8
staff create and sustain healthy workplaces. Paper surveys were distributed, which were completed at work. The survey included the Sinflo (Henderson et al 2012), a validated tool comprising 18 items that measure the following factors: ■■ Teamwork: staff consider they have the support of the team. ■■ Communication: staff are kept informed about unit situations and learning requirements. ■■ Recognition: staff are acknowledged by their leaders. ■■ Preparation: staff are prepared for their teaching role. ■■ Workload: staff workloads recognise their teaching responsibilities (Henderson et al 2012). It also included the Clocs (Henderson et al 2010) validated tool, comprising 28 items that measure five attributes recognised as important for quality learning environments: dissatisfaction, recognition, affiliation, accomplishment and influence. Staff responded to all 46 items using a Likert scale of one to five, where one indicated ‘strongly disagree’ and five ‘strongly agree’. Survey response Forty nine nurses completed the survey. There are more on the roster, but some were on extended leave. Twenty seven (55 per cent) completed the first survey before the project began and 24 (49 per cent) completed the second, follow-up survey. The roster comprises nearly all registered nurses (RNs) with five endorsed enrolled nurses, who are licensed nurses who must practise under RN supervision. It was not necessarily the same nurses who completed the pre- and post‑project surveys. Statistics Data were analysed using Stata 10 (Statacorp, Texas), a PC-based software statistical package. Descriptive statistics were used to examine survey respondents’ characteristics, and survey data were checked for anomalies in recording. Scoring for negatively worded questions were reversed. T-tests were used to compare pre- and post-project data for each of the subscales of the Sinflo and Clocs.
Findings All results for all subscales on the Sinflo and Clocs showed improvement, except for Influence. A number of these were statistically significant. Facilitating others’ learning Of the five subscales on the Sinflo, two – Acknowledgement and Teamwork – reported statistically significant differences (Table 1). These two subscales were the lowest, indicating a negative perception at the start of the NURSING MANAGEMENT
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Table 1 Results for Support Instrument for Nurses Facilitating the Learning of Others (Sinflo) Sinflo
Workload
Acknowledgement
Teamwork
Communication
Preparation
Pre-project, n=27
2.9
2.9
3.2
3.8
3.6
Post-project, n=24
2.9
3.4
3.6
3.9
3.9
Statistically significant
0.9
Yes P=0.04
Yes P=0.04
0.4
0.07
Accomplishment
Influence
Table 2 Results for Clinical Learning Organisational Culture Survey (Clocs) Clocs
Dissatisfaction score reversed
Recognition
Affiliation
Pre-project, n=27
3.09
3.60
4.08
4.01
3.00
Post-project, n=24
3.50
3.90
4.25
4.09
2.90*
Statistically significant
Yes 0.02
Yes 0.04
0.08
0.30.
0.08
* Score indicates a negative trend, however the subscale for influence has been reported as lacking clarity and is therefore not a good indicator
project. Unfortunately, staff perception of workload did not change across the time period; the NUM was unable to control this element. The two other subscales, Communication and Preparation, were not as low at the start of the project and the increase in these was not statistically significant. Clinical learning organisational culture Two of the five subscales on the Clocs were statistically significant (Table 2). Specifically, staff indicated less dissatisfaction and more recognition for their work. While two of the other subscales, Affiliation and Accomplishment, indicate trends in the desired direction, these results were not significant.
Discussion The findings from diarised notes and the surveys indicate that workplace behaviours can be modified when NUMs drive and model the change process. The particular changes in behaviour could be summarised as staff: ■■ Engaging less in gossiping and other negative behaviours. ■■ Seeking assistance from colleagues, who were happy to provide feedback. ■■ Replacing complaining with proactive communication. NURSING MANAGEMENT
Evidence of these behaviour changes could arguably be seen in the significant changes in staff perception of Acknowledgement and Teamwork (subscales in the Sinflo). The scores from analysis of the Sinflo pre- and 12 months after the NUM-initiated activities suggest that staff behaviour changed, so they were receptive, willing to collaborate, and actively engaged in giving feedback. Practices that increased a willingness to work and co-operate with one another may have affected the Dissatisfaction subscale, which was significantly reduced (Table 2). Influence did not alter during the project, which is a concern; however, the poor result on Clocs might be due to the difficulty in differentiating and clarifying the concept itself (Henderson et al 2010). Of particular interest is the Recognition subscale (Table 2); in other words, nurses considered that their work was more acknowledged, with higher scores in the Sinflo and Clocs surveys. This is perhaps attributable to the reward and recognition programme, which was important in motivating staff to participate and, subsequently, sustain their altered behaviours. The effectiveness of the reward and recognition programme was, arguably, its authenticity and its timeliness; it advocated for realistic and honest December 2013 | Volume 20 | Number 8 23
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Art & science | leadership feedback and appraisal, and was delivered in a short time, often during the same shift. Of significance was that the NUM managed these changes using existing resources and with support from nurse educators in the NPDU. Limitations The unit-based practices designed to encourage staff to engage positively in helping others appear to have been successful. However, not all staff were able to attend every session because of clinical workload, but those who were able to do so shared as much of their learning as possible. At the time these sessions were conducted, a number of clinical nurses were in temporary positions and, although the NUM encouraged them to feel comfortable about asserting themselves, some were less confident than the permanent staff about making significant changes because of their temporary status.
Conclusion Transformational leadership is important for high quality care delivery, and behaviours that nurse leaders inspire, role model and reinforce are instrumental in creating work practices that deliver optimum care. This is possible when NUMs initiate processes that enable staff to feel greater confidence about discussing and making changes in the workplace. This initiative shows that using rewards in everyday practice can be powerful in shifting perceptions about the value of high standards, teamwork and recognition of work. Values and attitudes commensurate with excellence in care can be embedded through responsive behavioural changes.
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Conflict of interest None declared
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