Leadership and Management by Nurse Managers by mef17219

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									64         NURSING RESEARCH

     Developing Leadership in Nurse
     Managers: The British Columbia
     Nursing Leadership Institute
     Maura MacPhee, RN, PhD
     Assistant Professor, University of British Columbia School of Nursing
     Academic Lead and Evaluator, British Columbia Nursing Administrative
     Leadership Institute for First Line Nurse Leaders
     Vancouver, BC

     France Bouthillette, RN, DNSc
     Adjunct Professor, University of British Columbia School of Nursing
     Executive Lead, British Columbia Nursing Administrative Leadership
     Institute for First Line Nurse Leaders
     Vancouver, BC

        The British Columbia Nursing Administrative Leadership Institute for First Line Nurse
        Leaders (BC NLI) is a collaborative partnership among British Columbia’s Chief
        Nursing Officers, the Ministry of Health Nursing Directorate and the University of
        British Columbia School of Nursing. This initiative consists of a four-day residential
        program and a year-long leadership project between BC NLI participants and their
        organizational mentors. The evidence-based curriculum covers universal leadership
        and management concepts, but it also addresses leadership issues of relevance to
        nurse leaders in today’s complex healthcare environments. The BC NLI is part of a
        provincial health human resources endeavour to ensure sufficient nursing leaders
        – for now and in the future. This paper will discuss the development, implementa-
        tion and evaluation of the BC NLI. Unique aspects of the program, such as its online
        networking component, will be described, and its role in nursing leadership research
        will be briefly examined.

     Effective nursing leadership has been credited with improved work environments,
     greater nurse satisfaction, lower nurse turnover and better quality of patient care
                  Developing Leadership in Nurse Managers: The British Columbia Nursing Leadership Institute   65

(CNAC 2002). There is a serious shortage of nurse leaders in Canada (Kilty 2005).
Laschinger and Wong (2007) recently completed a national study on the status
of nursing leadership in hospitals in which they found a significant reduction in
leadership positions resulting from 1990s downsizing activities and an average
age of 50 years for present nurse leaders (all levels). As these leaders retire, with-
out thoughtful human resources planning, the nursing leadership shortage will
worsen (O’Brien-Pallas et al. 2001).

Formal leadership development programs have become one strategy for devel-
oping nurse leaders (Contino 2004; Loo et al. 2003; Simpson et al. 2002). In this
paper, the authors describe a collaborative, evidence-based initiative between
British Columbia Chief Nursing Officers (CNOs), the Ministry of Health Nursing
Directorate (MoH) and the University of British Columbia School of Nursing
(UBC-SON). We also address the evaluation of the BC Nursing Administrative
Leadership Institute (BC NLI) and associated research.

Support for Leadership Development Programs
In business and government, leadership development programs are considered
a vital component of management training (Hamlin 2004). There are significant
financial payoffs for companies that invest in leadership training and develop-
ment (Krohn 2000). A meta-analysis of managerial leadership development
programs found that leadership training can result in significant knowledge and
skills improvement, although this outcome depends on matching the right learn-
ing opportunities to the right leaders (Collins and Holton 2004). The meta-analysis
included 103 leadership development studies with a range of interventions: 80%
were formal programs; other interventions included coaching/mentoring and on-
the-job training. The majority of these programs employed a 360-degree evalu-
ation approach with supervisors, peers and subordinates. The researchers of this
meta-analytic study concluded that successful leadership outcomes may depend
on matching participants’ educational objectives to an organization’s strategic
vision and goals. Organizational leadership needs assessments prior to training also
increase the probability of successful outcomes (Collins and Holton 2004).

Nursing leadership development programs have utilized a variety of theoretical
models and training strategies. A paper by Tourangeau et al. (2003), evaluating
the Toronto-based Dorothy M. Wylie Nursing Leadership Institute (DMW NLI),
provides an excellent overview of nursing leadership development programs
from the United States and the United Kingdom. Although leadership outcomes
varied by intervention and the focus of the evaluation, all the programs cited
by Tourangeau and colleagues demonstrated positive, significant short-term
outcomes from formal leadership training.
66     Nursing Leadership Volume 21 Number 3 • 2008

     In response to the recommendations of the Canadian Nurse Advisory Committee
     (CNAC 2002), the BC collaborative partners established a formal leadership devel-
     opment program, the BC NLI, for first-line nurse leaders within the province. The
     partners agreed that the objectives of the BC NLI would be (a) to assist novice
     first-line nurse managers with the development of a set of core management and
     leadership competencies and (b) to facilitate the application of management and
     leadership concepts and skills to real-life situations.

     To support the identification and development of current and future first-line
     nurse managers, the partners hired a consultant to conduct an extensive provincial
     needs assessment of first-line nurse leader competencies (Arcand 2003). A needs
     assessment prior to the development of a leadership program is seen as a way to
     better tailor curricular content and delivery to the needs of an intended audience
     (Collins and Holton 2004). The provincial needs assessment identified manage-
     ment and leadership competencies similar to those reported by Care and Udod
     (2003) and Hamlin (2004). The core competencies were categorized as under-
     standing leadership styles; team building and maintenance; organizational plan-
     ning and strategizing; change management process; empowerment and delega-
     tion; human resources planning and development; and communications (Arcand
     2003). The academic partner, UBC-SON, was tasked with creating, implementing
     and evaluating a BC NLI program based on the leadership development literature
     and the provincial needs assessment.

     The authors of this paper proceeded to organize the identified core competencies
     into a conceptual framework (Table 1). The BC NLI uses a Full Range Leadership
     model with an emphasis on transformational leadership augmented by trans-
     actional leadership (Bass et al. 2003). Participants learn how these two styles
     complement and enhance each other. This leadership training approach is similar
     to training approaches in other disciplines, such as Human Resources, Business
     Management and Organizational Development (Kelloway et al. 2000). To promote
     nursing leadership succession planning within the province, we wanted to use an
     approach that would facilitate BC NLI participants’ entry into Master of Business
     Administration or Master of Health Administration programs.

     Reviews of other leadership programs, such as the DMW NLI (Simpson et al.
     2002; Torangeau et al. 2003) and the Sigma Theta Tau International (STTI)
     Leadership Academy (STTI 2005) showed that the inclusion of a mentor-
     supported leadership project is an effective tool for practising and applying core
     competencies, such as change management, within an organizational context.
     Mentoring is a powerful tool for developing leadership potential in others
     (McKinley 2004). The development and implementation of a leadership project
                     Developing Leadership in Nurse Managers: The British Columbia Nursing Leadership Institute   67

with the support of a mentor from the participant’s organization has become an
integral part of the BC NLI experience.

 Table 1.                   Core competencies of the BC NLI curriculum

 Developing the Leader
 • Self-assessment
 • Understanding and using the power of influence
 • Developing your power base
 • Effective leadership styles
 • First-line nurse leaders: leading from the middle
 • First-line nurse leaders as change agents and innovators

 Leading Others
 • Empowering others
 • Team-building
 • Conflict management
 • Influence strategies
 • Healthy work environments

 Leading through Effective Planning
 • Change management
 • Project planning
 • Innovation strategies
 • Fiscal budgeting
 • Resource allocation
 • Developing work-related projects

 The Mentee–Mentor Relationship
 • Roles and responsibilities
 • Developing a mutual understanding
 • Identifying the mentee’s leadership learning objectives in relation to the project
 • Developing project description, goals and objectives

 Evaluative Responsibilities
 • Evaluation form
 • Project description, project updates, project reports
 • Career tracking
 • The portfolio (optional)

The pilot BC NLI was held in March 2005 in Harrison Hot Springs, BC.
Attendance was free for the participants, with conference costs covered by a CNAC
grant and CNO financial assistance. Curriculum development and delivery were
provided as in-kind support by UBC-SON. Twenty novice first-line nurse leaders
attended a three-day residential program. These participants were either new to
their leadership roles, had fewer than three years’ experience in a leadership posi-
tion or were being groomed for a leadership position within their organizations.
Participants were nominated by their CNOs to attend the BC NLI. In addition to
nominating novice nurse leader participants, the CNOs were also asked to identify
68     Nursing Leadership Volume 21 Number 3 • 2008

     a suitable expert nurse leader to act as a mentor for each participant. Participants
     represented a variety of healthcare settings: acute care, residential care and
     community and mental health.

     One month before the BC NLI, participants and their mentors received a prepara-
     tion packet asking them to identify a relevant leadership project they could work
     on together and realistically complete over the course of a year. This mentorship
     component and the project work were modelled after STTI’s original Maternal–
     Child Health Leadership Academy (STTI 2005).

     After the three-day residential program, participants returned to their respective
     organizations and were asked to reconnect with their mentors. Mentors were asked
     to commit set time periods to meet with their mentees, and to assist with the devel-
     opment, implementation and evaluation of mentees’ projects. They were also asked
     to assist their mentees with “learning the management ropes,” such as informal
     and formal networking channels to utilize within and outside the organization.
     The CNOs’ commitment to this initiative helped ensure adequate organizational
     support with respect to release time and resources for mentor–mentee projects.
     Patrick and Laschinger (2006) demonstrated significant associations among lead-
     ership empowerment, role satisfaction and adequate organizational support.

     Four months after the three-day residential program, mentor–mentee dyads were
     invited to attend a two-day follow-up session at UBC’s Vancouver campus. This
     time was solely devoted to project work, with UBC-SON faculty available for
     consultation. This follow-up session was also funded through the CNAC grant.
     At this session, participants were given portfolio templates for organizing their
     project materials. Although not a requirement of the BC NLI, participants were
     strongly encouraged to showcase their work in project portfolios. Portfolios are
     commonly used in other leadership communities, such as the business sector, to
     demonstrate project progress and outcomes. They can also be used to track indi-
     viduals’ professional growth and development, including ongoing learning needs
     (Brown 2002). At the end of a year, when participants were asked to provide a
     project report or summary, some participants produced project portfolios in lieu
     of a project report.

     The projects served as a vehicle for novice first-line nurse leaders to practise
     change management skills, to acquire systems-level knowledge of their organiza-
     tions and to continue to develop their leadership skills. Many projects dealt with
     significant practice environment issues, such as recruitment and retention of
     new graduate nurses, staff assimilation of internationally educated nurses, unit
     mergers, changes to care delivery models and skill mix, self-scheduling, practice
                  Developing Leadership in Nurse Managers: The British Columbia Nursing Leadership Institute   69

council development and the introduction of new technology (e.g., computerized
documentation and order entry). Based on the success of the first BC NLI cohort
(see below for evaluation details), funds were obtained to offer a second BC NLI
in 2006. The feedback prompted a decision to extend the residential program to
four days and to eliminate the two-day follow-up session. It proved to be more
cost-effective to offer a fourth day in Harrison Hot Springs for mentor–mentee
project work, and participants reported that it was very helpful for them to initiate
the project planning process while ideas and new knowledge were fresh in their
minds. In addition, the four-day residential gave all involved a rare opportunity to
focus on the project without interruptions.

Since the second BC NLI, the BC MoH Nursing Directorate has committed fund-
ing for the BC NLI through 2010. As part of a collective bargaining agreement, the
MoH has also allocated monies to create new first-line nurse leadership positions
(BC MoH 2007). The CNOs continue to support the BC NLI by nominating nurse
leaders and ensuring their attendance. UBC-SON has committed faculty and staff
support to provide three sessions per year, with each session accommodating 35
mentee–mentor dyads. It is anticipated that over 400 new nurse leaders will bene-
fit from the BC NLI over the next few years.

Program Description
The current BC NLI program consists of three major components: a four-day
residential workshop that delivers content on core leadership and management
competencies (Table 1); a mentor-supported leadership project that continues over
the course of a year within participants’ respective organizations; and a leadership
website that provides participants with online resources, chat space and lists of
provincially based leadership projects and project leader contact information.

The BC NLI faculty is typically from the UBC-SON, but guest speakers are invited
from other disciplines and institutions, such as UBC’s Sauder School of Business.
During each session, some time is allotted to discuss current topics and trends in
leadership and management, such as patient safety, Quality Improvement initia-
tives and operations management. A Sauder School business faculty recently
delivered a presentation on operations management, demonstrating the impor-
tance of systems analysis techniques to improve patient flow in a variety of hospi-
tal systems. These topics are intended to broaden participants’ appreciation for
contemporary leadership and management issues, and to sensitize them to new
vocabulary in the literature and in professional and academic communities.

At each BC NLI workshop, one of the BC CNOs is invited to deliver a welcom-
ing presentation at the first night’s “meet and greet” session. The CNOs often use
70     Nursing Leadership Volume 21 Number 3 • 2008

     this time in dialogue with nurse leaders about leadership and management issues
     of concern to them. Participants also provide a brief introduction to themselves,
     their work environment and their leadership projects.

     Throughout the remainder of the workshop, participants work together in round
     tables. The content is delivered as lectures interspersed with case studies and
     applied problems that require group work. Specific time is designated before and
     during evening meals for social and professional networking. On the last evening
     together, the mentors are invited to join their mentees for a buffet dinner. The
     following day is devoted to mentor–mentee project work, although time is also set
     aside to discuss BC NLI participant expectations, such as the completion of the
     year-long project.

     The importance of the mentor–mentee relationship is emphasized by the BC NLI
     faculty, and mentor–mentee dyads receive guidelines to develop and maintain
     their professional relationship, as well as a contract that details the terms of their
     professional commitments to each other. Successful mentor–mentee relationships
     depend on clear delineation of mentor–mentee roles and responsibilities, with
     specific terms of mentor–mentee commitment (Cox 2005; McKinley 2004).

     Some components of the BC NLI are similar to other programs, but there are
     other unique, evidence-based components, such as the emphasis on online knowl-
     edge networking. Online knowledge communities (OKCs) can serve as venues for
     continuing professional development, social supports for members and avenues
     for sharing and diffusing innovations (de Vries et al. 2004; Greenhalgh et al. 2004).
     Additional in-kind support through UBC-SON has provided the technological
     support necessary to create a leadership OKC at the BC NLI website (2008). There
     are several components to this website, including an online registration page for
     mentees and mentors, a resource centre to house leadership and management
     materials for participants, a discussion forum and a project page. Some pages,
     such as the registration pages, are accessible only to members, but other pages
     are publicly available. On the project page, for instance, the public and BC NLI
     participants can browse the site to see what types of projects are nurse-led within
     the province. Project access will hopefully increase networking among nurse lead-
     ers within British Columbia and reduce duplication of resources. Recently, for
     instance, members of different BC NLI cohorts discovered that they were working
     on similar skill mix issues. They were able to connect electronically to share a vari-
     ety of tools, policies and guidelines with one another. In the near future, we will
     be employing a knowledge broker to facilitate online networking and use of the
     BC NLI online resources. Knowledge brokering can enhance networking, resource
     utilization and the development and maintenance of OKCs (CHSRF 2007).
                  Developing Leadership in Nurse Managers: The British Columbia Nursing Leadership Institute   71

One of the online pages under construction will significantly contribute to our
provincial nurse leadership succession planning process. We are developing an
online career tracking page and database to determine how our BC NLI partici-
pants are evolving. Are they staying in first-line nurse leadership roles, or are
they progressing to mid-level and executive positions? Are they staying within
the same organization or the same Health Authority? BC NLI participants will
receive annual e-mail prompts to complete the online career tracking forms.
This career tracking process will provide us with valuable health human
resources data.

Evaluation of the British Columbia Nursing Leadership Institute
There have been two forms of BC NLI program evaluation: (a) a written evalua-
tion of BC NLI content and delivery at the end of the workshop and (b) project
progress reports. Formal interviews were conducted with mentors and mentees as
part of the BC NLI pilot evaluation in 2006.

Written evaluations
Open-ended evaluation questions offer participants such prompts as: “the most
beneficial part of the BC NLI was…,” “I would change…,” “A new idea for me
was….” Favourable written evaluations have demonstrated the relevancy of the
content, the value of the delivery format, an immediate positive effect on the nurse
leaders’ attitude towards their jobs and an improved sense of confidence in their
leadership abilities. Several BC NLI participants have said that attendance at the
workshop renewed their faith in and commitment to their work, particularly their
leadership and management roles and responsibilities. One participant said: “I
had my resignation ready to go in my desk. I have new confidence in myself and
my ability to be an effective leader. I actually have the tools to do it!”

Since the inception of the BC NLI, the authors have utilized feedback from the
workshop evaluations to modify and strengthen the program’s content and deliv-
ery. Some program changes have included more interactive sessions and more
time for informal networking. Additional content has been added to the sessions
on conflict management, team-building and fiscal planning and resource allo-
cation. Notably, every BC NLI cohort has requested more content on conflict
management and “dealing with power dynamics.”

Project progress reports
The online project page has simplified the task of recording and evaluating project
progress. After the workshop, participants are asked to record their project titles
and summaries on the BC NLI project page. Participants have access to one
another’s information, and each participant has the option of making his or her
72     Nursing Leadership Volume 21 Number 3 • 2008

     information publicly accessible. E-mail reminders are sent out to participants if
     they do not complete their project summaries by specific dates after the work-
     shop. Participants receive e-mail notices at six months to complete a brief project
     update online, and at the end of the year, participants are electronically prompted
     to complete an online project report that includes an overview of their leader-
     ship successes and challenges. Some participants have produced project portfolios
     that have been used for undergraduate or graduate academic credits. During the
     workshop, participants are given a portfolio binder with a table of contents and
     content descriptions that enable them to apply for academic credit through UBC
     and other provincial colleges and universities.

     The first cohort of BC NLI participants completed their year-long program in
     March 2006. A purposive sample of mentors and mentees were interviewed in the
     summer of 2006. Approval to conduct mentee–mentor interviews was obtained
     from UBC’s Institutional Review Board, and all interviewees formally consented.
     Mentor–mentee dyads were interviewed from each of the six provincial Health
     Authorities. A total of eight interviews were conducted within the mentees’ and
     mentors’ work environments in private locations. For each dyad, some of the
     questions were privately addressed to the mentee, some were privately addressed
     to the mentor and some were addressed to the dyad. The entire interview proc-
     ess averaged an hour in length. The key areas explored during the interviews were
     the strengths and weaknesses of the BC NLI program, the project successes and
     challenges and the mentoring process. The purpose of these questions was to
     determine how future BC NLI offerings could be strengthened to better ensure
     successful outcomes for participants and their respective mentors and organiza-
     tions. The audiotapes of the interviews were transcribed and independently coded
     and analyzed for recurring major themes by a graduate student assistant and one
     of the authors (Miles and Huberman 1994).

     The mentee interviews yielded the following themes with respect to the BC NLI’s
     successes or strengths: dialogue and networking with peers, having the tools
     to succeed, feeling valued and time away for reflection. Pertaining to project
     successes, the predominant mentee theme was succeeding at change: “I learned the
     organizational lingo to get along – and the tools to succeed at managing change.
     I feel more comfortable and confident around other managers.” Mentees’ biggest
     project impediments were lack of organizational support, changes of priorities
     within the organization and picking the wrong project. Some mentees picked
     projects of interest to them, but if these were not part of their formal duties or
     responsibilities, they frequently had to abandon their projects. “I had this whole
     new job to learn, and every single portion of it was a learning process. And then I
     had the project besides. … I ran out of energy.”
                  Developing Leadership in Nurse Managers: The British Columbia Nursing Leadership Institute   73

Mentors’ interviews focused more on project successes and challenges, and their
comments mirrored their mentees’ statements. Mentors and mentees independ-
ently acknowledged the importance of organizational support, especially with
respect to release time and resources to work on the leadership projects. One
mentor said: “There has to be protected time and resources, otherwise, you’re not
going to be able to keep moving ahead.”

Mentors and mentees equally valued the mentoring process and reported benefits
from the relationship. Mentees particularly appreciated the opportunity to reflect
confidentially on their practice with their mentors. Mentors appreciated the oppor-
tunity to “to think outside the box for a change. … you get asked questions and you
have to start thinking – really thinking and learning. It’s a reciprocal process.”

While we have some evidence that supports the importance of nursing leader-
ship development programs, many program evaluations have been limited to
pre–post self- and other questionnaires, with post- assessments occurring within
a year of program completion. Tourangeau and colleagues (2003) evaluated lead-
ership outcomes from the DMW NLI. After three months, self-reports of leader-
ship practices did not significantly change from a baseline assessment, but other
reports (e.g., those of supervisors, peers) noted significant increases in partici-
pants’ leadership behaviours. Similar findings were reported from a meta-analysis
of leadership development program research from 1982 to 2001 (Collins and
Holton 2004). Self-reports of leadership behavioural change were not significant,
but other reports were. This variance may be due to individual leaders’ tendency
to evaluate themselves more critically (Collins et al.; Tourangeau et al.).

A dearth of research exists with respect to long-term outcomes of nursing lead-
ership development programs. One of the authors (MacPhee) is the principal
investigator for a Canadian Health Services Research Foundation (CHSRF)
research grant to evaluate the structure and the process of leadership development
program delivery with respect to nurse leader and nursing staff outcomes. This
study is framed as a testable leadership development program logic model that
includes theoretically derived program inputs, activities, outputs and outcomes.
This research program is funded over four years, enabling the research team to
explore long-term outcomes from the BC NLI. The BC NLI was selected for this
research because it focuses on novice nurse leaders with limited preparation for
their first-line leadership positions. BC NLI participants also represent nurse lead-
ers from diverse practice settings across the province. The goal of this research is
to add additional weight to the evidence that supports the importance of nursing
leadership development.
74     Nursing Leadership Volume 21 Number 3 • 2008

        The BC NLI is an evidence-based nursing leadership development program
        that utilizes a variety of contemporary leadership and management theories
        as its conceptual foundation. The delivery format has borrowed from some
        exemplary nursing leadership development programs, and the content and
        delivery format have been honed over time through a variety of evalua-
        tion processes. To ensure the life expectancy of this valuable program, the
        BC NLI is being highlighted in a four-year research study that will enable
        the research team to track leadership outcomes with respect to leadership
        succession planning within one province, and it will help to determine the
        factors that significantly influence successful leadership outcomes, such as
        organizational supports.

     We offer our sincere thanks for the support we have received from the collabo-
     rative partners for the British Columbia Nursing Administrative Leadership
     Institute for First Line Nurse Leaders, University of British Columbia School of
     Nursing, British Columbia Ministry of Health Nursing Directorate and British
     Columbia Chief Nursing Officers.

     Correspondence may be addressed to: Maura MacPhee, Assistant Professor,
     University of British Columbia School of Nursing, T239-2211 Westbrook Mall,
     University of British Columbia, Vancouver, British Columbia, V6T2B5; phone: 604-
     822-2891; email: Maura.macphee@nursing.ubc.ca

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