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THE JOURNAL OF NURSING ADMINISTRATION
Transformational Leadership Practices of Nurse Leaders in Professional Nursing Associations Erin J. Ross, DNP, ANP-BC, CORLN Joyce J. Fitzpatrick, PhD, RN, FAAN Elizabeth R. Click, ND, RN, CWP
Helene J. Krouse, PhD, RN Joanne T. Clavelle, DNP, RN, NEA-BC, FACHE
OBJECTIVE: This study describes the transformational leadership (TL) practices of nurse leaders in professional nursing associations (PNAs). BACKGROUND: Professional nursing associations are vehicles to provide educational opportunities for nurses as well as leadership opportunities for members. Little has been published about the leadership practices of PNA members. METHOD: E-mail surveys of 448 nurse leaders in PNAs were conducted in 2013 using the Leadership Practices Inventory (LPI). RESULTS: The top 2 TL practices of these nurse leaders were enabling others to act and encouraging the heart. Respondents with more leadership training reported higher TL practices. CONCLUSION: This is the 1st study to describe TL practices of nurse leaders in PNAs. Results of this study show that nurse leaders of PNAs emulate practices of TL. Transformational leaders can mobilize
and direct association members in reaching shared values, objectives, and outcomes. Understanding TL practices of nurse leaders in PNAs are important to the future of nursing in order to enable nurses to lead change and advance health through these organizations.
Author Affiliations: Doctor of Nursing Practice and Certified Adult Nurse Practitioner (Dr Ross), Head & Neck Institute, Cleveland Clinic, Beachwood, Ohio; Elizabeth Brooks Ford Professor of Nursing (Dr Fitzpatrick); Assistant Professor (Dr Click), Francis Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio; Medical Director (Dr Click), Case Western Reserve University, Cleveland, Ohio; Professor of Nursing (Dr Krouse), College of Nursing, Wayne State University, Detroit, Michigan; Senior Vice President and Chief Clinical Officer (Dr Clavelle), Scottsdale Healthcare, Arizona. Partial funding received to complete the project was presented to Dr Ross in the form of nursing research grants. Grant funding was awarded from Sigma Theta Tau International Alpha Mu Chapter and the Society of Otorhinolaryngology & Head-Neck Nursing. The authors declare no conflicts of interest. Correspondence: Dr Ross, Cleveland Clinic Beachwood Family Health Center, 26900 Cedar Rd, Suite 315 S, Beachwood, OH 44122 ([email protected]). DOI: 10.1097/NNA.0000000000000058
JONA Vol. 44, No. 4 April 2014
The nursing profession is the largest segment of the US healthcare workforce with more than 3 million members.1 The 2010 Institute of Medicine’s (IOM’s)1 Future of Nursing report identifies a need for resilient and proficient nursing leadership. Professional nursing associations (PNAs) provide leadership development through mentoring and best practice opportunities for members. The goals of PNAs include education of members, other professional health providers, and the public about the nursing specialty. Professional nursing associations provide a means for obtaining continuing education, establish standards of practice and ethics, and provide a culture that promotes leadership among members to further serve the profession. Being a member of a professional association demonstrates dedication and commitment to the profession and to professional growth on behalf of the members.2 Transformational Leadership Transformational leadership (TL) is a form of social influence that has broad applicability in nursing. Transformational leadership is a leadership style that inspires and empowers followers to achieve extraordinary outcomes while transcending individual selfinterests, aligning objectives and goals of the followers, the leader, groups, and the organization.3 Transformational leadership is a distinct model that provides an empirically supported approach to foster organizational
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and personal change.4 Transformational leadership has been found to be highly effective in creating a highly engaged organizational culture.3 Transformational leaders support excellence in practice by appealing to the higher ideals and values of their followers. Nurse leaders should embody these values. Transformational leadership, compared with other forms of leadership, is associated with lower rates of burnout,5,6 a better sense of leader effectiveness,7 and better staff satisfaction.6,8-10 Use of TLs can produce environments with higher rates of employee retention, productivity, and job satisfaction.11,12 Further TL development leads to improved organizational strategies and better patient outcomes.12 The IOM1 recognizes the need for a wide variety of nursing bodies to focus on providing leadership development, mentoring programs, and entrepreneurial opportunities for nurses. Transformational leaders have the power to develop and support future generations of leaders with the aptitude to create effective strategies to some of the profession’s most critical issues.11
Background of TL Transformational leadership practices were 1st described by Burns13 in his theory of leadership. His theory was extended by the work of Bass,14 who defined how TL could be measured and how it influences follower enthusiasm and performance. Bass14 proposed a theory that portrays how leaders affect and move their followers and organizations by transforming them. Influenced by Bass and Avolio’s3 transformational model of leadership, Kouzes and Posner15 developed a model of exemplary leadership and described 5 leadership practices: enabling others to act, encouraging the heart, inspiring a shared vision, challenging the process, and modeling the way. Definitions of these leadership practices16 are as follows:
Modeling the way: finding voice and clarifying
personal values by setting an example and aligning actions with the shared values of the team When leaders were getting extraordinary things done in organizations, they were emulating these 5 practices.16(p27) Leadership is among the most widely studied behaviors by organizational behaviorists, psychologists, and human resource researchers in organizations.17,18 There is empirical research suggesting the benefits of TL.19-21
Related Studies of TL Among Nurse Leaders Leadership has been studied among nursing leaders.6,8,9,14,18,21,22 There are a number of studies that directly address TL among nurse leaders. DunhamTaylor23 found that as the nurse executive’s TL score increased, the hospital organization was more participative. Chiok Foong Loke,24 Leach,25 and McGuire and Kennerly26 recognized significant relationships between TL practices and organizational commitment. Wylie and Gallagher27 explored self-reported TL behavior profiles; seniority and prior leadership training were positively related to TL. Failla and Stichler8 found a significant relationship between nurse manager TL style and job satisfaction. Furthermore, researchers have shown that strong leaders improve outcomes by contributing to improved quality and patient safety,28 lowering patient mortality,29 and enhancing work environments.30 Transformational leadership practices of nurse leaders have not been studied in PNAs to date, even though these leaders have potential to shape many others in the profession as well as practice. This study was designed to fill the void in our understanding of leadership practices of leaders in professional nursing organizations.
Inspiring a shared vision: envisioning the future
by imagining exciting and ennobling possibilities; enlisting others in common vision by appealing to shared aspirations Challenging the process: searching for opportunities by seeking new ways to change, grow, and improve; experimenting and taking risks; generating small wins; and learning from mistakes Enabling others to act: fostering collaboration by promoting cooperative goals and building trust and strengthening others by sharing power and discretion along the way Encouraging the heart: recognizing individual contributions, showing appreciation for excellence, and celebrating victories by creating a spirit of community
202
Methods This descriptive study included RNs in defined leadership positions (president, vice president, past president, and members of boards of directors) in PNAs. Prior to data collection, institutional review board approval was obtained. E-mail addresses (n = 448) of potential nurse leaders participants were obtained from the Web site of the PNAs. The nurse leader was invited to a link on the SurveyMonkey Web site, where the informed consent and survey were available. The next contact was at 2 weeks, with an e-mail postcard thanking those who had participated and reminding those who had not completed the survey. The data collection period was 6 weeks. Data were downloaded
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into the Statistical Package for the Social Sciences using IBM SPSS Statistics version 20 (Ireland).
Table 1. Sample Characteristics (n = 134)
Instrument
Variable
The Leadership Practices Inventory (LPI)YSelf is a 30-item questionnaire containing 5 subscales for each of The Five Practices of Exemplary Leadership: inspiring a shared vision, encouraging the heart, enabling others to act, modeling the way, and challenging the process.33 Each subscale contains 6 questions, with a 10-point Likert response scale, with 1 considered low and 10 considered high. A high level of internal consistency is reported in the LPI34 with Cronbach’s " scores of .70 to .84 and high test-retest reliability of 0.93 to 0.95 with the specific subscale reliabilities as follows: enabling others to act (0.91), encouraging the heart (0.86), inspiring a shared vision (0.91), challenging the process (0.86), and modeling the way (0.84). In the present study, the Cronbach’s " scores ranged from .70 to .88: enabling others to act (.70), encouraging the heart (.80), inspiring a shared vision (.88), challenging the process (.85), and modeling the way (.77). The LPI has been used in 2 studies of leadership practices among nurse leaders in Magnet hospitals. Porter-O’Grady31 compared 71 Magnet chief nursing officers (CNOs) and 90 non-Magnet CNOs, with results demonstrating no significant differences between the 2 groups. The mean (SD) LPI scores for Magnet CNOs were as follows: inspiring a shared vision, 8.63 (0.77); challenging the process, 8.61 (0.79); enabling others to act, 9.16 (0.53); modeling the way, 8.86 (0.66); and encouraging the heart, 8.71 (0.76). Clavelle et al32 provided new evidence that the top 2 TL practices of CNOs in Magnet organizations are enabling others to act and modeling the way. The LPI subscale score of enabling others to act was significantly higher than that of modeling the way (t = 6.78, P G .001), encouraging the heart (t = 8.85, P G .001), inspiring a shared vision (t = 7.33, P G .001), and challenging the process (t = 10.50, P G .001). According to these researchers, as CNOs gain experience and education, they exhibit more TL characteristics. Demographic information obtained in the study included gender, year born, race, education, certification, primary nursing specialty, work status, nursing association specialty, residing state, office held, years in leadership, years as member of nursing association, number of members and level of office (national, regional or local), amount of leadership training, current position, and title.
Gender Female Male Missing data Race White Black/African American American Indian/Alaska Native Other Education Diploma Associate Bachelor’s Master’s PhD DNP Missing data Certification Yes No Work status Full-time Part-time PRN Retired Student Office held President President-elect Past president Vice president Board of director Missing data Years in leadership G1 1-2 3-5 6-10 11-15 16-20 21-25 925 Missing data No. of members G100 101-250 251-500 501-750 751-1,000 1,001-5,000 5,001-10,000 910,000 Missing data Years in PNA 1-2 3-5 6-10 11-15 16-20 21-25 925 Missing Amount of leadership training A great deal A lot A moderate amount A little None at all Missing data
A
Result One hundred thirty-four (n = 134) nurse leaders completed the survey, a response rate of 30% (Table 1). Of
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n
%
113 20 1
84.3 14.9 0.7
128 3 2 1
99.5 2.2 1.5 0.7
2 5 13 73 14 21 6
1.5 3.7 9.7 54.5 10.4 15.7 4.5
98 36
73.1 26.9
108 15 4 4 6
80.6 11.2 3.0 4.5 0.7
35 7 29 12 40 11
26.1 5.2 21.6 9.0 29.9 8.2
8 12 27 33 13 11 7 21 2
6.0 9.0 20.1 24.6 9.7 8.2 5.2 15.7 1.5
16 8 15 10 8 47 7 21 2
11.9 6.0 11.2 7.5 6.0 35.1 5.2 15.7 1.5
3 23 33 22 9 9 34 1
2.2 17.2 24.6 16.4 6.7 6.7 25.4 0.7
29 18 44 29 13 1
21.6 13.4 32.8 21.6 9.7 0.7
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Table 2. Descriptive Statistics of the LPI Subscales Challenge the Process n Mean SD Minimum Maximum
134 8.1704 1.09843 3.67 10.0
Enable Others to Act
Encourage the Heart
134 8.7724 0.66212 6.33 10.0
134 8.6119 0.89480 6.00 10.0
Model the Way
Inspire A Shared Vision
134 8.5037 .92186 4.50 10.0
134 8.2164 1.21017 3.33 10.0
Data in bold represent the top 2 transformational leadership practices of nurse leaders in PNAs.
those who answered the demographic questions (n = 133), the majority was female with a graduate degree and professional certification. Nurse leaders from 37 states participated. Office held included president, president-elect, past president, vice president, and board of directors. There were more than 50 different nursing specialty associations reported by the participants. The top 2 TL practices of nurse leaders in a PNA were enabling others to act and encouraging the heart. Leadership Practices InventoryYSelf mean and SD results for all subscales are reported in Table 2. Additional Analyses To identify relationships between means of the LPISelf and how much leadership training was acquired, Pearson correlations were calculated. Respondents with more leadership training reported higher TL practices, modeling the way (r = 0.296, P G .001), inspiring a shared vision (r = 0.320, P G .001), challenging the process (r = 0.240, P G .05), enabling others to act (r = 0.193, P G .05), and encouraging the heart (r = 0.212, P G .05). To determine differences between office held and LPI-Self, analysis of variance tests were conducted. There were no significant differences in 5 LPI subscales based on the office held.
Discussion This was the 1st study to identify TL practices of nurse leaders in PNAs. The top 2 TL practices of nurse leaders in a PNA were enabling others to act and encouraging the heart. Enabling others to act
relates to fostering collaboration and strengthening others. Leaders in PNAs are in an ideal position to promote cooperative goals and make each member feel competent and confident. Encouraging the heart is recognizing individual contributions and celebrating in team accomplishments. Leaders in PNAs can create a culture in which there is recognition of peers and celebration of accomplishments, thus incorporating the mission of the association. In the present study, there was similarity between CNOs of Magnet hospital and nurse leaders in PNAs. There are 2 other studies describing TL in nurse leaders in organizations. Porter-O’Grady31 compared Magnet CNOs and non-Magnet CNOs using the LPI and found no statistically significant differences. Clavelle et al32 reported that the top 2 TL practices of CNOs in Magnet organizations were enabling others to act and modeling the way. The LPI subscale of enabling others to act is 1 of the top 2 reflected in the present study as well as Clavelle and colleagues’32 study. These results reflect that CNOs of Magnet hospitals and nursing leaders in PNAs see themselves as enabling others to act. Overall, Magnet CNOs and nurse leaders of PNAs perceive themselves as transformational. The subscale of challenge the process had the lowest means for all 3 studies (Table 3). This is an interesting finding; nurse leaders are less likely to view themselves as challenging the process. Identifying effective leadership styles and skills required by nurse leaders to evolve and transform today’s healthcare issues, including challenging existing processes, is necessary to reach the transformational recommendations set in IOM’s Future of Nursing report.1
Table 3. Comparison of Means of Previous Studies Using LPI in Nursing31,32
Ross et al (current study) Clavelle et al32 Porter-O’Grady31
Model the Way
Inspire a Shared Vision
Challenge the Process
Enable Others to Act
Encourage the Heart
8.50 (0.921) 8.39 (0.872) 8.81 (0.67)
8.21 (1.21) 8.22 (1.05) 8.51 (0.92)
8.17 (1.10) 8.16 (0.909) 8.50 (0.85)
8.77 (0.662) 8.70 (0.674) 9.17 (0.57)
8.61 (0.895) 8.17 (1.10) 8.61 (0.95
Values are mean (SD). Data in bold represent that the number 1 transformational leadership practice is the same among all 3 studies compared.
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Leading a PNA entails getting extraordinary things done. It takes modeling the way, inspiring a shared vision, challenging the process, enabling others to act, and encouraging the heart to meet the mission and vision of the PNA. Leaders of PNAs foster collaboration and actively involve other members to meet the strategic goals of the association. Leaders of PNAs role model and open the way for leadership development of the members. Limitations The study is limited by being the 1st to study TL in nursing leaders of PNAs; thus, there are no studies for comparison. The LPI was administered as selfassessment and was not combined with an observational 360-degree data collection process (members in the PNA). Thus, the findings are limited to how nurse leaders of PNAs view their own leadership style. The transformational model may have some potential limitations so it is possible that the claim made by participants regarding the extent of TL in nursing is exaggerated.35 For the execution of the survey, it was difficult to obtain the e-mail addresses of nursing leaders. Many PNAs do not wish to share their Listserv stating privacy reasons, so the study was limited to nurse leaders whose e-mail addresses were publicly listed on the organization Web site.
Recommendations for Future Research This study should be replicated with a large sample. Further investigation with research into leadership development and improved outcomes is warranted. Opportunity exists in a future research initiative to explore the variable of the current office held and research each office independently exploring outcomes and implications. The IOM report1 suggests nurses should be full partners with physicians and other healthcare professionals. It would be interesting to further research the finding of low scoring means of challenge the process from the 3 reported studies compared in Table 3. Understanding why leaders rate this quality so low in themselves and changing this perception or
reality is important to transformation of practice and healthcare in the future.
Conclusion Professional nursing associations have the opportunity to create cultures that promote and value leadership. Transformational leadership is a model that provides an approach to foster organizational and personal change. Transformational leadership practices can be learned by those seeking to strengthen their abilities and maybe as easily adaptable to other settings36 such as PNAs. Achieving extraordinary accomplishments in a PNA can be challenging and takes the dedication from leaders and members. Professional nursing association’s leaders must identify priorities in support of the IOM’s report on the Future of Nursing recommendations1 and take responsibility for executing those recommendations on multiple levels. Professional nursing associations and nurse leaders should foster leadership development and mentoring programs throughout their associations to enhance the organizational outcomes as well as the experiences of the members. Seasoned nurse leaders have a responsibility to support the development of the novice nurse in multiple settings including at the bedside, in the boardroom, and PNAs.37 Leaders in PNAs can promote leadership activities among their membership, encouraging them to participate on committees and boards, both internal and external to the association.1 The TL can mobilize and direct the association members in reaching shared values, objectives, and outcomes. Elected association leaders today remain responsible to their members and through TL practices should incorporate members’ input into advancing healthcare, thus allowing members to contribute to the voice of the profession through PNAs.38
Acknowledgments The authors thank the Alpha Mu Chapter of Sigma Theta Tau and the Society of Otorhinolaryngology & Head-Neck Nurses for supporting this research through educational grants.
References 1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. 2010. http://www.iom.edu/Reports/2010/ The-Future-of-Nursing-Leading-Change-Advancing-Health. Accessed October 9, 2012. 2. White MJ, Olson RS. Factors affecting membership in specialty nursing organizations. Rehabil Nurs. 2004;29(4): 131-137. 3. Bass B, Avolio B. Transformational leadership and organizational culture. Public Adm Q. 1993;17(1):112-121.
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4. Gabel S. Transformational leadership in medical practice: capturing and influencing principle-driven work. J Ambul Care Manage. 2012;35(4):304-310. 5. Corrigan PW, Diwan S, Campion J, Rashid F. Transformational leadership and the mental health team. Adm Policy Mental Health. 2003;30(2):97-108. 6. Weberg D. Transformational leadership and staff retention: an evidence review with implications for healthcare systems. Nurs Adm Q. 2010;34(3):246-258.
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7. Xirasagar S, Samuels ME, Stoskopf CH. Physician leadership styles and effectiveness: an empirical study. Med Care Res Rev. 2005;62(6):720-740. 8. Failla KR, Stichler JF. Manager and staff perceptions of the manager’s leadership style. J Nurs Adm. 2008;38(11):480-487. 9. Larrabee JH, Janney MA, Ostrow CL, Witbrow ML, Hobbs GR, Burant C. Predicting registered nurse job satisfaction and intent to leave. J Nurs Adm. 2003;33(5):271-283. 10. Spinelli RJ. The applicability of Bass’s model of transformational, transactional, and laissez-faire leadership in the hospital administrative environment. Hosp Top. 2006;84(2):11-18. 11. Ward K. A vision for tomorrow: transformational nursing leaders. Nurs Outlook. 2002;50(3):121-126. 12. Wong C, Cummings G. The relationship between nursing leadership and patient outcomes: a systematic review. J Nurse Manag. 2007;15:508-521. 13. Burns J. Leadership. New York, NY: Harper and Row; 1978. 14. Bass BM. Leadership and Performance. New York, NY: Free Press; 1985. 15. Kouzes JM, Posner BZ. The Leadership Challenge: How To Get Extraordinary Things Done in Organizations. San Francisco, CA: Jossey-Bass; 1987. 16. Kouzes JM, Posner BZ. The Leadership Challenge. 4th ed. San Francisco, CA: Jossey-Bass; 2008. 17. Helms MM, ed. Leadership theories and studies. In: Encyclopedia of Management. Volume 1. 2006. http://www.enotes.com/ leadership-theories-studies-reference. Accessed November 5, 2012. 18. Tuna M, Ghazzawi I, Tuna A, /atir O. Transformational leadership and organizational commitment: the case of Turkey’s hospitality industry. SAM Adv Manag J. 2011;76(3):10-25. 19. Bass B. On the taming of charisma: a reply to Janice Beyer. Leadersh Q. 1999;10:541-553. 20. Bass BM, Jung DI, Avolio BJ, Berson Y. Predicting unit performance by assessing transformational and transactional leadership. J Appl Psychol. 2003;88(2):207-218. 21. Wong CA, Cummings GG. The relationship between nursing leadership and patient outcomes: a systematic review. J Nurs Manag. 2007;15(5):508-521. 22. Cummings GG, MacGregor T, Davey M, et al. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. International Journal of Nursing Studies. 2010;47(3):363-385. 23. Dunham-Taylor J. Nurse executive transformational leadership found in participative organizations. J Nurs Adm. 2000;30(5): 241-250.
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24. Chiok Foong Loke J. Leadership behaviours: effects on job satisfaction, productivity and organizational commitment. J Nurs Manag. 2001;9(4):191-204. 25. Leach L. Nurse executive transformational leadership and organizational commitment. J Nurs Adm. 2005;35(5):228-237. 26. McGuire E, Kennerly S. Nurse managers as transformational and transactional leaders. Nursing Economics. 2006;24(4): 179-185. 27. Wylie DA, Gallagher HL. Transformational leadership behaviors in allied health professions. Journal of Allied Health. 2009;38(2):65-73. 28. Mastal MF, Joshi M, Schulke K. Nursing leadership: championing quality and patient safety in the boardroom. Nursing Economics. 2007;25(6):323-330. 29. Cummings GG, Midodzi WK, Wong CA, Estabrooks CA. The contribution of hospital nursing leadership styles to 30-day patient mortality. Nurs Res. 2010;59(5):331-339. 30. Sherman R, Pross E. Growing future nurse leaders to build and sustain healthy work environments at the unit level. Online J Issues Nurs. 2010;15(1). 31. Porter-O’Grady T. Creating a context for excellence and innovation: comparing chief nurse executive leadership practices in Magnet and non-Magnet hospitals. Nurs Adm Q. 2009;33(3):198-204. 32. Clavelle JT, Drenkard K, Tullai-McGuinness S, Fitzpatrick JJ. Transformational leadership practices of chief nursing officers in MagnetA organizations. J Nurs Adm. 2012;42(4): 195-201. 33. Posner BZ, Kouzes JM. Development and validation of the Leadership Practices Inventory. Educ Psychol Meas. 1988; 48(2):483-496. 34. Posner BZ. Leadership practices inventory (LPI) data analysis. 2010. http://media.wiley.com/assets/2260/07/LPIData AnalysisSept2010.pdf. Accessed October 5, 2012. 35. Hutchinson M, Jackson D. Transformational leadership in nursing: towards a more critical interpretation. Nurs Inq. 2013;20(1):11-22. 36. Heuston MM, Wolf GA. Transformational leadership skills of successful nurse managers. J Nurs Adm. 2011;41(6):248-257. 37. Hassmiller SB, Reinhard S. The Institute of Medicine Report on the Future of Nursing: a legacy for nursing leadership. Nurse Lead. 2011;9(6):30-32. 38. Matthews J. Role of professional organizations in advocating for the nursing profession. Online J Issues Nurs. 2012;17(1): Manuscript 3.
JONA Vol. 44, No. 4 April 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF NURSING ADMINISTRATION
Transformational Leadership Practices of Nurse Leaders in Professional Nursing Associations Erin J. Ross, DNP, ANP-BC, CORLN Joyce J. Fitzpatrick, PhD, RN, FAAN Elizabeth R. Click, ND, RN, CWP
Helene J. Krouse, PhD, RN Joanne T. Clavelle, DNP, RN, NEA-BC, FACHE
OBJECTIVE: This study describes the transformational leadership (TL) practices of nurse leaders in professional nursing associations (PNAs). BACKGROUND: Professional nursing associations are vehicles to provide educational opportunities for nurses as well as leadership opportunities for members. Little has been published about the leadership practices of PNA members. METHOD: E-mail surveys of 448 nurse leaders in PNAs were conducted in 2013 using the Leadership Practices Inventory (LPI). RESULTS: The top 2 TL practices of these nurse leaders were enabling others to act and encouraging the heart. Respondents with more leadership training reported higher TL practices. CONCLUSION: This is the 1st study to describe TL practices of nurse leaders in PNAs. Results of this study show that nurse leaders of PNAs emulate practices of TL. Transformational leaders can mobilize
and direct association members in reaching shared values, objectives, and outcomes. Understanding TL practices of nurse leaders in PNAs are important to the future of nursing in order to enable nurses to lead change and advance health through these organizations.
Author Affiliations: Doctor of Nursing Practice and Certified Adult Nurse Practitioner (Dr Ross), Head & Neck Institute, Cleveland Clinic, Beachwood, Ohio; Elizabeth Brooks Ford Professor of Nursing (Dr Fitzpatrick); Assistant Professor (Dr Click), Francis Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio; Medical Director (Dr Click), Case Western Reserve University, Cleveland, Ohio; Professor of Nursing (Dr Krouse), College of Nursing, Wayne State University, Detroit, Michigan; Senior Vice President and Chief Clinical Officer (Dr Clavelle), Scottsdale Healthcare, Arizona. Partial funding received to complete the project was presented to Dr Ross in the form of nursing research grants. Grant funding was awarded from Sigma Theta Tau International Alpha Mu Chapter and the Society of Otorhinolaryngology & Head-Neck Nursing. The authors declare no conflicts of interest. Correspondence: Dr Ross, Cleveland Clinic Beachwood Family Health Center, 26900 Cedar Rd, Suite 315 S, Beachwood, OH 44122 ([email protected]). DOI: 10.1097/NNA.0000000000000058
JONA Vol. 44, No. 4 April 2014
The nursing profession is the largest segment of the US healthcare workforce with more than 3 million members.1 The 2010 Institute of Medicine’s (IOM’s)1 Future of Nursing report identifies a need for resilient and proficient nursing leadership. Professional nursing associations (PNAs) provide leadership development through mentoring and best practice opportunities for members. The goals of PNAs include education of members, other professional health providers, and the public about the nursing specialty. Professional nursing associations provide a means for obtaining continuing education, establish standards of practice and ethics, and provide a culture that promotes leadership among members to further serve the profession. Being a member of a professional association demonstrates dedication and commitment to the profession and to professional growth on behalf of the members.2 Transformational Leadership Transformational leadership (TL) is a form of social influence that has broad applicability in nursing. Transformational leadership is a leadership style that inspires and empowers followers to achieve extraordinary outcomes while transcending individual selfinterests, aligning objectives and goals of the followers, the leader, groups, and the organization.3 Transformational leadership is a distinct model that provides an empirically supported approach to foster organizational
201
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and personal change.4 Transformational leadership has been found to be highly effective in creating a highly engaged organizational culture.3 Transformational leaders support excellence in practice by appealing to the higher ideals and values of their followers. Nurse leaders should embody these values. Transformational leadership, compared with other forms of leadership, is associated with lower rates of burnout,5,6 a better sense of leader effectiveness,7 and better staff satisfaction.6,8-10 Use of TLs can produce environments with higher rates of employee retention, productivity, and job satisfaction.11,12 Further TL development leads to improved organizational strategies and better patient outcomes.12 The IOM1 recognizes the need for a wide variety of nursing bodies to focus on providing leadership development, mentoring programs, and entrepreneurial opportunities for nurses. Transformational leaders have the power to develop and support future generations of leaders with the aptitude to create effective strategies to some of the profession’s most critical issues.11
Background of TL Transformational leadership practices were 1st described by Burns13 in his theory of leadership. His theory was extended by the work of Bass,14 who defined how TL could be measured and how it influences follower enthusiasm and performance. Bass14 proposed a theory that portrays how leaders affect and move their followers and organizations by transforming them. Influenced by Bass and Avolio’s3 transformational model of leadership, Kouzes and Posner15 developed a model of exemplary leadership and described 5 leadership practices: enabling others to act, encouraging the heart, inspiring a shared vision, challenging the process, and modeling the way. Definitions of these leadership practices16 are as follows:
Modeling the way: finding voice and clarifying
personal values by setting an example and aligning actions with the shared values of the team When leaders were getting extraordinary things done in organizations, they were emulating these 5 practices.16(p27) Leadership is among the most widely studied behaviors by organizational behaviorists, psychologists, and human resource researchers in organizations.17,18 There is empirical research suggesting the benefits of TL.19-21
Related Studies of TL Among Nurse Leaders Leadership has been studied among nursing leaders.6,8,9,14,18,21,22 There are a number of studies that directly address TL among nurse leaders. DunhamTaylor23 found that as the nurse executive’s TL score increased, the hospital organization was more participative. Chiok Foong Loke,24 Leach,25 and McGuire and Kennerly26 recognized significant relationships between TL practices and organizational commitment. Wylie and Gallagher27 explored self-reported TL behavior profiles; seniority and prior leadership training were positively related to TL. Failla and Stichler8 found a significant relationship between nurse manager TL style and job satisfaction. Furthermore, researchers have shown that strong leaders improve outcomes by contributing to improved quality and patient safety,28 lowering patient mortality,29 and enhancing work environments.30 Transformational leadership practices of nurse leaders have not been studied in PNAs to date, even though these leaders have potential to shape many others in the profession as well as practice. This study was designed to fill the void in our understanding of leadership practices of leaders in professional nursing organizations.
Inspiring a shared vision: envisioning the future
by imagining exciting and ennobling possibilities; enlisting others in common vision by appealing to shared aspirations Challenging the process: searching for opportunities by seeking new ways to change, grow, and improve; experimenting and taking risks; generating small wins; and learning from mistakes Enabling others to act: fostering collaboration by promoting cooperative goals and building trust and strengthening others by sharing power and discretion along the way Encouraging the heart: recognizing individual contributions, showing appreciation for excellence, and celebrating victories by creating a spirit of community
202
Methods This descriptive study included RNs in defined leadership positions (president, vice president, past president, and members of boards of directors) in PNAs. Prior to data collection, institutional review board approval was obtained. E-mail addresses (n = 448) of potential nurse leaders participants were obtained from the Web site of the PNAs. The nurse leader was invited to a link on the SurveyMonkey Web site, where the informed consent and survey were available. The next contact was at 2 weeks, with an e-mail postcard thanking those who had participated and reminding those who had not completed the survey. The data collection period was 6 weeks. Data were downloaded
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into the Statistical Package for the Social Sciences using IBM SPSS Statistics version 20 (Ireland).
Table 1. Sample Characteristics (n = 134)
Instrument
Variable
The Leadership Practices Inventory (LPI)YSelf is a 30-item questionnaire containing 5 subscales for each of The Five Practices of Exemplary Leadership: inspiring a shared vision, encouraging the heart, enabling others to act, modeling the way, and challenging the process.33 Each subscale contains 6 questions, with a 10-point Likert response scale, with 1 considered low and 10 considered high. A high level of internal consistency is reported in the LPI34 with Cronbach’s " scores of .70 to .84 and high test-retest reliability of 0.93 to 0.95 with the specific subscale reliabilities as follows: enabling others to act (0.91), encouraging the heart (0.86), inspiring a shared vision (0.91), challenging the process (0.86), and modeling the way (0.84). In the present study, the Cronbach’s " scores ranged from .70 to .88: enabling others to act (.70), encouraging the heart (.80), inspiring a shared vision (.88), challenging the process (.85), and modeling the way (.77). The LPI has been used in 2 studies of leadership practices among nurse leaders in Magnet hospitals. Porter-O’Grady31 compared 71 Magnet chief nursing officers (CNOs) and 90 non-Magnet CNOs, with results demonstrating no significant differences between the 2 groups. The mean (SD) LPI scores for Magnet CNOs were as follows: inspiring a shared vision, 8.63 (0.77); challenging the process, 8.61 (0.79); enabling others to act, 9.16 (0.53); modeling the way, 8.86 (0.66); and encouraging the heart, 8.71 (0.76). Clavelle et al32 provided new evidence that the top 2 TL practices of CNOs in Magnet organizations are enabling others to act and modeling the way. The LPI subscale score of enabling others to act was significantly higher than that of modeling the way (t = 6.78, P G .001), encouraging the heart (t = 8.85, P G .001), inspiring a shared vision (t = 7.33, P G .001), and challenging the process (t = 10.50, P G .001). According to these researchers, as CNOs gain experience and education, they exhibit more TL characteristics. Demographic information obtained in the study included gender, year born, race, education, certification, primary nursing specialty, work status, nursing association specialty, residing state, office held, years in leadership, years as member of nursing association, number of members and level of office (national, regional or local), amount of leadership training, current position, and title.
Gender Female Male Missing data Race White Black/African American American Indian/Alaska Native Other Education Diploma Associate Bachelor’s Master’s PhD DNP Missing data Certification Yes No Work status Full-time Part-time PRN Retired Student Office held President President-elect Past president Vice president Board of director Missing data Years in leadership G1 1-2 3-5 6-10 11-15 16-20 21-25 925 Missing data No. of members G100 101-250 251-500 501-750 751-1,000 1,001-5,000 5,001-10,000 910,000 Missing data Years in PNA 1-2 3-5 6-10 11-15 16-20 21-25 925 Missing Amount of leadership training A great deal A lot A moderate amount A little None at all Missing data
A
Result One hundred thirty-four (n = 134) nurse leaders completed the survey, a response rate of 30% (Table 1). Of
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n
%
113 20 1
84.3 14.9 0.7
128 3 2 1
99.5 2.2 1.5 0.7
2 5 13 73 14 21 6
1.5 3.7 9.7 54.5 10.4 15.7 4.5
98 36
73.1 26.9
108 15 4 4 6
80.6 11.2 3.0 4.5 0.7
35 7 29 12 40 11
26.1 5.2 21.6 9.0 29.9 8.2
8 12 27 33 13 11 7 21 2
6.0 9.0 20.1 24.6 9.7 8.2 5.2 15.7 1.5
16 8 15 10 8 47 7 21 2
11.9 6.0 11.2 7.5 6.0 35.1 5.2 15.7 1.5
3 23 33 22 9 9 34 1
2.2 17.2 24.6 16.4 6.7 6.7 25.4 0.7
29 18 44 29 13 1
21.6 13.4 32.8 21.6 9.7 0.7
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Table 2. Descriptive Statistics of the LPI Subscales Challenge the Process n Mean SD Minimum Maximum
134 8.1704 1.09843 3.67 10.0
Enable Others to Act
Encourage the Heart
134 8.7724 0.66212 6.33 10.0
134 8.6119 0.89480 6.00 10.0
Model the Way
Inspire A Shared Vision
134 8.5037 .92186 4.50 10.0
134 8.2164 1.21017 3.33 10.0
Data in bold represent the top 2 transformational leadership practices of nurse leaders in PNAs.
those who answered the demographic questions (n = 133), the majority was female with a graduate degree and professional certification. Nurse leaders from 37 states participated. Office held included president, president-elect, past president, vice president, and board of directors. There were more than 50 different nursing specialty associations reported by the participants. The top 2 TL practices of nurse leaders in a PNA were enabling others to act and encouraging the heart. Leadership Practices InventoryYSelf mean and SD results for all subscales are reported in Table 2. Additional Analyses To identify relationships between means of the LPISelf and how much leadership training was acquired, Pearson correlations were calculated. Respondents with more leadership training reported higher TL practices, modeling the way (r = 0.296, P G .001), inspiring a shared vision (r = 0.320, P G .001), challenging the process (r = 0.240, P G .05), enabling others to act (r = 0.193, P G .05), and encouraging the heart (r = 0.212, P G .05). To determine differences between office held and LPI-Self, analysis of variance tests were conducted. There were no significant differences in 5 LPI subscales based on the office held.
Discussion This was the 1st study to identify TL practices of nurse leaders in PNAs. The top 2 TL practices of nurse leaders in a PNA were enabling others to act and encouraging the heart. Enabling others to act
relates to fostering collaboration and strengthening others. Leaders in PNAs are in an ideal position to promote cooperative goals and make each member feel competent and confident. Encouraging the heart is recognizing individual contributions and celebrating in team accomplishments. Leaders in PNAs can create a culture in which there is recognition of peers and celebration of accomplishments, thus incorporating the mission of the association. In the present study, there was similarity between CNOs of Magnet hospital and nurse leaders in PNAs. There are 2 other studies describing TL in nurse leaders in organizations. Porter-O’Grady31 compared Magnet CNOs and non-Magnet CNOs using the LPI and found no statistically significant differences. Clavelle et al32 reported that the top 2 TL practices of CNOs in Magnet organizations were enabling others to act and modeling the way. The LPI subscale of enabling others to act is 1 of the top 2 reflected in the present study as well as Clavelle and colleagues’32 study. These results reflect that CNOs of Magnet hospitals and nursing leaders in PNAs see themselves as enabling others to act. Overall, Magnet CNOs and nurse leaders of PNAs perceive themselves as transformational. The subscale of challenge the process had the lowest means for all 3 studies (Table 3). This is an interesting finding; nurse leaders are less likely to view themselves as challenging the process. Identifying effective leadership styles and skills required by nurse leaders to evolve and transform today’s healthcare issues, including challenging existing processes, is necessary to reach the transformational recommendations set in IOM’s Future of Nursing report.1
Table 3. Comparison of Means of Previous Studies Using LPI in Nursing31,32
Ross et al (current study) Clavelle et al32 Porter-O’Grady31
Model the Way
Inspire a Shared Vision
Challenge the Process
Enable Others to Act
Encourage the Heart
8.50 (0.921) 8.39 (0.872) 8.81 (0.67)
8.21 (1.21) 8.22 (1.05) 8.51 (0.92)
8.17 (1.10) 8.16 (0.909) 8.50 (0.85)
8.77 (0.662) 8.70 (0.674) 9.17 (0.57)
8.61 (0.895) 8.17 (1.10) 8.61 (0.95
Values are mean (SD). Data in bold represent that the number 1 transformational leadership practice is the same among all 3 studies compared.
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Leading a PNA entails getting extraordinary things done. It takes modeling the way, inspiring a shared vision, challenging the process, enabling others to act, and encouraging the heart to meet the mission and vision of the PNA. Leaders of PNAs foster collaboration and actively involve other members to meet the strategic goals of the association. Leaders of PNAs role model and open the way for leadership development of the members. Limitations The study is limited by being the 1st to study TL in nursing leaders of PNAs; thus, there are no studies for comparison. The LPI was administered as selfassessment and was not combined with an observational 360-degree data collection process (members in the PNA). Thus, the findings are limited to how nurse leaders of PNAs view their own leadership style. The transformational model may have some potential limitations so it is possible that the claim made by participants regarding the extent of TL in nursing is exaggerated.35 For the execution of the survey, it was difficult to obtain the e-mail addresses of nursing leaders. Many PNAs do not wish to share their Listserv stating privacy reasons, so the study was limited to nurse leaders whose e-mail addresses were publicly listed on the organization Web site.
Recommendations for Future Research This study should be replicated with a large sample. Further investigation with research into leadership development and improved outcomes is warranted. Opportunity exists in a future research initiative to explore the variable of the current office held and research each office independently exploring outcomes and implications. The IOM report1 suggests nurses should be full partners with physicians and other healthcare professionals. It would be interesting to further research the finding of low scoring means of challenge the process from the 3 reported studies compared in Table 3. Understanding why leaders rate this quality so low in themselves and changing this perception or
reality is important to transformation of practice and healthcare in the future.
Conclusion Professional nursing associations have the opportunity to create cultures that promote and value leadership. Transformational leadership is a model that provides an approach to foster organizational and personal change. Transformational leadership practices can be learned by those seeking to strengthen their abilities and maybe as easily adaptable to other settings36 such as PNAs. Achieving extraordinary accomplishments in a PNA can be challenging and takes the dedication from leaders and members. Professional nursing association’s leaders must identify priorities in support of the IOM’s report on the Future of Nursing recommendations1 and take responsibility for executing those recommendations on multiple levels. Professional nursing associations and nurse leaders should foster leadership development and mentoring programs throughout their associations to enhance the organizational outcomes as well as the experiences of the members. Seasoned nurse leaders have a responsibility to support the development of the novice nurse in multiple settings including at the bedside, in the boardroom, and PNAs.37 Leaders in PNAs can promote leadership activities among their membership, encouraging them to participate on committees and boards, both internal and external to the association.1 The TL can mobilize and direct the association members in reaching shared values, objectives, and outcomes. Elected association leaders today remain responsible to their members and through TL practices should incorporate members’ input into advancing healthcare, thus allowing members to contribute to the voice of the profession through PNAs.38
Acknowledgments The authors thank the Alpha Mu Chapter of Sigma Theta Tau and the Society of Otorhinolaryngology & Head-Neck Nurses for supporting this research through educational grants.
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