Anonson et al-2014-Journal of Nursing Management PDF

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Journal of Nursing Management, 2014, 22, 127–136

Qualities of exemplary nurse leaders: perspectives of frontline nurses JUNE ANONSON R N , P h D 1, MARY ELLEN WALKER SITHOKOZILE MAPOSA R N , P h D 3, PATTI TELFORD

2 3 R N , B S N , EBIN ARRIES R N , P h D , 4 5 R N and LOIS BERRY R N , P h D

1

Associate Professor, College of Nursing, University of Saskatchewan, Prince Albert, Saskatchewan, 2Graduate Student, College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, 3Assistant Professor, College of Nursing, University of Saskatchewan, Prince Albert, Saskatchewan, 4Nursing Consultant, Deloitte and Touche, Vancouver, British Columbia and 5Associate Dean, College of Nursing, University of Saskatchewan, Prince Albert, Saskatchewan, Canada

Correspondence June Anonson College of Nursing University of Saskatchewan 1301 Central Avenue Prince Albert Saskatchewan Canada S6V 4W1 E-mail: [email protected]

ANONSON J., WALKER M.E., ARRIES E., MAPOSA S., TELFORD P. & BERRY L. (2014) Journal of Nursing Management 22, 127–136. Qualities of exemplary nurse leaders: perspectives of frontline nurses

Aim This paper reports on a study that looked at the characteristics of exemplary nurse leaders in times of change from the perspective of frontline nurses. Background Large-scale changes in the health care system and their associated challenges have highlighted the need for strong leadership at the front line. Methods In-depth personal interviews with open-ended questions were the primary means of data collection. The study identified and explored six frontline nurses’ perceptions of the qualities of nursing leaders through qualitative content analysis. This study was validated by results from the current literature. Results The frontline nurses described several common characteristics of exemplary nurse leaders, including: a passion for nursing; a sense of optimism; the ability to form personal connections with their staff; excellent role modelling and mentorship; and the ability to manage crisis while guided by a set of moral principles. All of these characteristics pervade the current literature regarding frontline nurses’ perspectives on nurse leaders. Conclusion This study identified characteristics of nurse leaders that allowed them to effectively assist and support frontline nurses in the clinical setting. Implications for nursing management The findings are of significance to leaders in the health care system and in the nursing profession who are in a position to foster development of leaders to mentor and encourage frontline nurses. Keywords: characteristics, frontline nurses, nursing leadership, organisational development, qualitative descriptive, staff nurses Accepted for publication: 1 March 2013

Qualities of exemplary nurse leaders: perspectives of frontline nurses Exemplary leadership in nursing is acknowledged as being more critical now than ever. According to the Canadian Nurses Association, leadership plays a

crucial role in the lives of registered nurses and is key in ensuring quality client outcomes, especially during times of significant upheaval in health care (Kilty 2005). Research has established that nursing leadership is a critical factor in the effective functioning of nursing units, high-quality patient care, retention of

DOI: 10.1111/jonm.12092 ª2013 John Wiley & Sons Ltd

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nurses and organisational effectiveness (Dolan 2003, American Association of Critical Care Nurses 2005, American Organization of Nurse Executives 2005, Anthony et al. 2005). The 1990s proved to be a time of great strain on nurse leaders, with massive restructuring and layoffs prefacing the nursing shortages seen in the first decade of the new millennium (McIntyre & McDonald 2010). In recent years, the financial restrictions and the increased workload associated with the nursing shortage have made the leadership role in nursing more complex (Rosengren et al. 2007). The large-scale changes in the health care system that have resulted from the restructuring of administrative roles, the shrinking of fiscal and human resources, new technologies, the emphasis on quality improvement and patient safety, and the increase in patient numbers have highlighted the need for strong leadership. Nurse leaders are being challenged to do more with less and their work is made even more complex by the competing goals that increasingly influence nursing practice. Nursing staffs are, for example, held accountable to the economic goals in organisations that are increasingly driven by business models. These goals are not necessarily aligned with the ethic of care on which professional nursing practice has traditionally been based (McIntyre & McDonald 2010). Excellence in nursing leadership continues to be the adhesive force that holds the health care system together. This is a truth that is not bound by geographic borders. In an investigative study in Jordan, for example, Mrayyan and Khasawneh (2008) established that ‘nurse leaders are the internal stakeholders of any health care organisation’. In this study, questionnaires were distributed to nurse leaders and the findings concluded that most Jordanian nurse leaders use supportive leadership behaviours. This study is evidence that nurse leadership is important in different cultures, and nursing leadership is a global nursing issue. Around the globe, excellence in nursing is the path to quality patient care and the key to the development of excellence is strong nursing leadership. The purpose of this article is to compare what the current literature states about the qualities that frontline nurses desire in nurse leaders with a study that examined the same topic in 2001. The study from 2001 was completed in the context of the aforementioned turbulence in the health care system that happened throughout the 1990s. Comparing this 2001 study with the current literature is an opportunity to examine similarities in the perceptions frontline nurses have about nursing leadership in different contexts

throughout time. In the 2001 study, the aim was to collect six frontline nurses’ perceptions of exemplary leadership in the leaders with whom they had worked. The study interviewed frontline nurses in 2001 and reported on their experiences in the health care system in Alberta (Canada) from 1990 to 1999. The study used an interpretive methodology built on social constructivist approaches to knowing by offering the frontline nurses (both junior and senior) opportunities to articulate and expand upon their experiences within a professional context. The examination of these results against the current literature allows for understanding of the traits frontline nurses perceive as important in nurse leaders throughout time.

Leadership traits and qualities: a review of the literature The 2001 study addressed frontline nurses’ experience of leadership during a decade of dramatic change in the health care system in the Province of Alberta. The primary research question that guided the inquiry was: what do frontline nurses who profess to have experienced exemplary leadership perceive to be the qualities of exemplary nurse leaders? In this study, the definition of qualities or traits is consistent with the view of Ogawa and Bossert (2000) that they are complex, dynamic and embedded in context and relationships. Ogawa and Bossert (2000) identified four basic assumptions that underlie most treatments of leadership: function, role, the individual and culture. Trait theory addresses leaders as individuals possessing certain attributes and demonstrating certain behaviours. From this perspective, ‘traits and actions of individuals identified the currency and medium of leadership’ (Ogawa & Bossert 2000). This view of trait theory recognizes the interactive and reciprocal nature of leadership (Chen et al. 2008). The present study identified the interactive and relational qualities that the interviewees considered valuable. All known previous research at the time of the study assessed perceptions of exemplary leadership qualities from the perspectives of nurse leaders. Upenieks’ (2002) qualitative study, which identified core principles, guiding values and passion for nursing as central to leadership effectiveness, looked at leadership from the perspective of an elite group of nurse leaders. Her study showed that leaders who were readily involved in interprofessional mentorship and collaborative teamwork improved patient outcomes (Upenieks 2002). Nurse leaders who could use their knowledge effectively were able to ‘mobilize resources, and get ª2013 John Wiley & Sons Ltd

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whatever they need for the goals they are trying to meet’. Our study is similar to that of Upenieks (2002) in the use of qualitative research approaches to evaluate perspectives on the quality of leadership but it differs in that it gathered data from frontline nurses rather than from the leaders themselves. In the years since our study was completed, literature has been published that addresses the views of frontline nurses on leadership. However, these studies were not necessarily completed during a time of such significant health care transformation as was taking place in Alberta in the 1990s. Rouse (2009) lists the qualities that staff want in leaders as: clear communication; availability for meetings; ability to face problems head-on; obtaining staff input; not instilling fear of reprisal or discipline; the setting of ground rules to decrease bias; being available; listening to staff concerns; and creating a positive atmosphere. Rouse (2009) also cited Rosengren et al. (2007), who stated that staff wanted present and available leaders. The literature shows that exemplary leaders understand and act in a manner consistent with the specific situation that they are facing. Effective leaders have the ability to motivate and engage the people they lead. ‘The leader who is engaged and passionate about work will communicate this to staff who will then feel the contagion and the excitement’ (Kerfoot 2008). Raup (2008) adds that transformational leadership is the preferred style of leadership by staff, explaining that this leadership style involves mentoring and being charismatic, educational, encouraging and communicative. Dolan (2003) states that ‘Transformational leaders involve their staff through sharing of information and vision, challenging them to think creatively, and coaching them in problem solving’. There may also be a correlation between transformational leadership and emotional intelligence. Akerjordet and Severinsson (2008) state that emotional intelligence is characterized by self-awareness, personal self-efficacy, interpersonal control and self-confidence, and is one of the traits listed in transformational leadership. Leaders who understand their own emotional quotient and that of their staff are better able to guide and lead their staff and organisations effectively (Feather 2009). A study by Steinert et al. (2006) showed that nurses had a positive view of others in leadership positions who shared their leadership, including physicians who shared leadership with nurses. These nurses thought that shared leadership allowed for greater discussion of patient-related problems; however, physicians viewed shared leadership less favourably than did nurses.

According to McKenna et al. (2004), nurses thought that leaders should be able to spot and nurture leadership in others, as well as having clear thinking, sensitivity, clear communication, courage, willingness to participate and a good work ethic. In addition to wanting specific traits in their leaders, nurses can identify traits that are not seen as desirable. Rouse (2009) cited the types of failed leadership set out by Kellerman (2005) as incompetent, rigid, intemperate, callous, corrupt, insular and evil. Rouse explained that staff were not satisfied with leaders who were not available, avoided conflict, were incompetent, were unaware of workplace issues, had poor interpersonal skills, had a lack of training and did not follow up with concerns. Raup (2008) discussed two kinds of leadership that can be problematic: transactional leadership, which rewards compliance and disciplines staff members for failure to follow rules, and leadership that is passive and involves no discipline (called ‘passive-avoidant’ leadership). One might wonder how leadership styles affect the workplace beyond individual relationships. Rouse (2009) listed the consequences of poor leadership as including low productivity, absenteeism, high turnover, disengagement and low morale. Conversely, consequences of good leadership include good morale, staff retention, high enthusiasm and team spirit, understanding of goals, sense of belonging, high patient satisfaction, respect, open communication, collaboration and empowerment (Steinert et al. 2006, Akerjordet & Severinsson 2008, Raup 2008, Rouse 2009). These outcomes serve as a motivator for those who put nurses in leadership positions to find individuals who are strong leaders and to foster that leadership. Canadian nurse leader Ginette Lemire Rodger suggests that successful leaders embody four primary attributes: the ability to translate vision into reality; the knowledge and confidence to deal with uncertainty; and commitment to being visible as nurses (McIntyre & McDonald 2010). Nursing literature over time has frequently identified four types of leadership qualities: communication skills (Feltner et al. 2008, Rouse 2009); the ability to be a visionary (Campbell 1998, Lafferty 1998, Hibberd & Smith 1999, Hernon & Rossiter 2006); orientation toward mentoring (Upenieks 2002, McKenna et al. 2004); and the ability to empower others (Campbell 1998, Upenieks 2002, Feltner et al. 2008). The literature emphasizes the importance of studying qualities from a systemic perspective, in which context and relationships are critical and leadership is viewed as a reciprocal process.

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Research methods The study completed in 2001 identified and explored six frontline nurses’ perceptions of the qualities of nursing leaders, employing a qualitative–constructivist content-analysis approach. This approach assumes the existence of multiple realities, co-created by people in the natural world, which aim to understand the social world (Denzin & Lincoln 2000). In-depth personal interviews asking open-ended questions were the primary means of data collection. The Department of Educational Policy Studies Ethics Review Committee at the University of Alberta approved the research methods used in the study. The study used purposive sampling procedures to select the participants; these were frontline nurses that had worked with nurse leaders in the health care system in the Province of Alberta between 1990 and 1999. The participants ranged in age from their mid-20s to their mid-50s and were chosen based on their proximity to the researcher, their accessibility and their diverse experience. Table 1 includes each nurse participant’s background information (pseudonyms used). The questions used in the study were first pilot-tested with nursing colleagues of the researcher to determine Table 1 Characteristics of participants Participant Patrick

Sandra

Ann

Sarah

Celine

Julia

Background Late 20s, the youngest nurse interviewed Chose a career against the mainstream – a profession that included predominantly females Described his experience of being a frontline nurse as ‘challenging, stressful, and very rewarding’ Mid 30s; 10 years of nursing experience Viewed her nursing experiences as primarily negative; criticized health care cuts and felt a lack of recognition, support and solidarity among nurses Mid 40s; 20+ years of experience Returned to school to finish her degree Enjoyed nursing, optimistic about her nursing experience 10+ years of experience in both acute and community care Has been a frontline nurse; worked as a charge nurse for a short time; worked as a frontline nurse, educator, and planner for a nursing programme at the time of the interview Described her frontline nursing experience as ‘Very, very busy! Very busy!’ 15 years experience in acute care mental health facilities with inpatients and outpatients Has worked as a frontline nurse, supervisor and nurse educator Mid 50s; most experienced study participant Worked as a frontline nurse and nurse manager. Worked in a community agency; created a volunteer nursing role that later evolved into a staff position

if changes needed to be made. The study participants responded to these questions, which were mailed to them before the actual interview. The interviews were approximately 60 minutes in length, and were conducted in each interviewee’s preferred location. They included exploratory and open-ended questions. The audio-taped interviews were transcribed, and each participant received a copy of the transcript to make any necessary changes, deletions and clarifications, ensuring that the data represented his or her intentions. Follow-up interviews gave the participants an opportunity to clarify or change any part of their transcribed interviews and allowed for further explanation or expansion of ideas. The final stage of the data collection included the participants’ review of sections of the final study, which included data from their transcripts. In addition, the researcher regularly updated a journal that detailed the research process.

Interpretive data analysis The researcher read the transcripts and listened to the interview tapes multiple times. Next, the transcribed interviews were coded to differentiate the various categories and classifications of emerging themes. Using inductive analysis, broad categories and then themes were identified across some or all of these categories. In accordance with the theory of confirmability developed by Denzin and Lincoln (2000), which ensures both coherence and correspondence of the data, at each step the researcher assessed confirmability of the thematic categorization with a peer auditor and the study participants. For the purposes of this study, the approach of Lincoln and Guba (1985) was used to establish credibility. The data and data-collection processes were verified through peer audits, member checks and audit trails. This qualitative study included sufficient thick description (Lincoln & Guba 1985) to ensure that readers could understand the effect of differences in situations on the results. Analysis produced information that allowed others to identify similarities to their own situations, but was not designed to be deductive or conclusively categorical.

Results: reading across the stories This study presented the perspectives of the six nurse participants as stories that described nurse leaders whom they viewed as exemplary. Each story introduced the ‘leader nurse’ and discussed his or her personal attributes and leadership qualities. These qualities were clasª2013 John Wiley & Sons Ltd

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sified by the researcher into several categories discussed below.

Passion for nursing: optimism Each of the participants in this study described exemplary nurse leaders as having a passion for nursing and optimism about the ability of the nurses in their charge to deal with the difficult circumstances. Such passion for nursing is particularly noteworthy during a time of turbulence. McIntyre and McDonald (2010) note that the pervasive distrust of the system that arose in the 1990s resulted in demoralized nurses with little willingness to take up leadership roles. It is possible that nurse leaders without a passion for the profession and a sense of optimism would be unable to persevere and provide the kind of leadersh...